The Joint Commission has issued a Sentinel Event Alert concerning the
use of blood thinners following several high profile errors related to
their use.
From 1997-2007, there were 31 reported sentinel events related to anticoagulants affecting 34 patients. Of these 34 patients, 28 died.
The alert offers 15 specific steps to help organizations reduce the risk to patients from incorrect administering, the use of the wrong drug or other causes of anticoagulation-related sentinel events. These steps, which cover suggestions for use of all anticoagulants, and also actions just for heparin and warfarin, include:
- Assess the risks of using anticoagulants.
- Use best practices or evidence-based guidelines regarding anticoagulants.
- Establish standard dose limits on anticoagulants and require that a doctor confirm any exceptions.
- Clearly label syringes and other containers used for anticoagulants.
- Clarify all anticoagulant dosing for pediatric patients, who are higher risk because these drugs are formulated and packaged for adults.
Read The Joint Commission’s anticoagulation Sentinel Event Alert.