The Joint Commission Issues Alert Concerning Commonly Used Anticoagulants by ProQuest

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									The Joint Commission Issues Alert Concerning
Commonly Used Anticoagulants
         n Sept. 24, 2008, the Joint Commission released its 41st             newer assay methods, and an expanding list of drug interactions and

O        Sentinel Event Alert (“SEA”) concerning accidental
         deaths and overdosing due to the improper use of
anticoagulant drugs.
                                                                              potential reversal strategies, (iii) failure to document or communicate
                                                                              specific and individualized instructions and monitoring information
                                                                              during handoffs, and (iv) problems treating neonates and other pediatric
   The Joint Commission warned that anticoagulants, specifically              patients because the medications are formulated and packaged primarily
heparin, warfarin, and enoxaparin, are one of the top five drug types         for adults. Patients receiving heparin and warfarin are at greater risk
associated with patient safety incidents in the United States. Citing the     because these anticoagulants have narrow therapeutic ranges and a high
United States Pharmacopeia MEDMARX database, the Joint Commission             potential for complications.
reported that 59,316 medication errors related to anticoagulants were             As with all medications, anesthesia professionals should obtain
reported from 2001 to 2006, 60 percent of which reached the patient,          patient histories regarding use of anticoagulants and carefully screen for
with 3 percent resulting in harm or death. Contributing factors to these      contraindications and drug interactions before all procedures.
medication errors are listed as (i) lack of standardization for the naming,       Read the complete SEA at http://www.jointcommission.org/
labeling and packaging of anticoagulants, (ii) difficulty in keeping          SentinelEvents/SentinelEventAlert/sea_41.htmI
current with different dosing regimens for various patient populations,       Source: The Joint Commission.




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