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Joint Commission Issues Anticoagulant Event Alert

Advisory group recommends implementation of strategies to reduce medication errors

MONDAY, Sept. 29 (HealthDay News) -- Specific risk reduction strategies can help prevent errors in the administration of anticoagulants that often result in harm or death, according to a Sentinel Event Alert published Sept. 24 by The Joint Commission, which accredits and certifies more than 15,000 health care organizations and programs in the United States.

Patrick J. Brennan, M.D., chair of the Sentinel Event Advisory Group, and colleagues state that anticoagulants account for 7.2 percent of the medication-related sentinel events in their database and that two-thirds of such events involved heparin. They also state that a total of 59,316 anticoagulant-related medical errors were reported to the United States Pharmacopeia MEDMARX program between 2001 and 2006, nearly 3 percent of which resulted in harm or death.

The Sentinel Event Advisory Group recommends including all staff who manage anticoagulants -- physicians, nurses, pharmacists, dieticians and case managers -- in the implementation of risk-reduction strategies. They cite guidelines developed by the United Kingdom's National Patient Safety Agency, the Institute for Safe Medication Practices, and the Institute for Healthcare Improvement to improve staff communication and access to information, pharmacy oversight and involvement, and patient education.

"In addition, organizations may consider: Implementing a pharmacist-managed anticoagulation service. In addition to helping discharged patients receiving warfarin therapy, this service can assist staff caring for patients on all types of anticoagulants. [Also,] implementing or using, when available, computerized provider order entry and/or bar coding technology. Pharmacy can use bar coding to replenish regular anticoagulant medication stock or automated dispensing cabinets," the authors state.

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