Joint Commission releases latest Sentinel Event Alert targeting anticoagulants

Patient Safety Monitor Insider

October 1, 2008

 The Joint Commission has released its latest Sentinel Event Alert targeting anticoagulant use and medical errors. This is the fourth alert The Joint Commission has issued this year. There have been a number of high-profile medical errors involving anticoagulants in the national media, and The Joint Commission’s alert is intended to offer methods for preventing further errors.

This is not the first time The Joint Commission has targeted anticoagulants. Requirements introduced into the 2008 National Patient Safety Goals are set to hit the point of full implementation on January 1, 2009. The Joint Commission also addresses anticoagulants under the medication management standards.

Common factors in anticoagulant errors highlighted in The Joint Commission’s report include labeling and packaging issues, documentation errors, communication failures, and inappropriate use of medication.

For more information or to view the Sentinel Event Alert itself, go to The Joint Commission’s Web site here.