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
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.
Acupressure Calms above the left eyebrow that has no
reported clinical effects.
Children before Surgery Thirty minutes later, the
researchers noted decreased anxi-
n acupressure treatment applied to children undergoing anesthe- ety levels in the child