Sentinel Event Alert #41
Errors Relating to Commonly used Anticoagulants
On September 24, 2008, the Joint Commission distributed a Sentinel Event Alert regarding errors relating to commonly used anticoagulants. The new Sentinel Event Alert discusses the importance of anticoagulation safety and how health care organizations that dispense or administer anticoagulant medications can prevent errors by implementing specific risk reduction strategies. Joint Commission Resources has the following tools to help educate your organization on this very important topic.
Toolkit
Anticoagulation Therapy:
Toolkit for Implementing the National Patient Safety Goal
Anticoagulation is a high-risk treatment. Too much medication could lead to major bleeding, and too little means clots could form. This new toolkit provides essential components to establish and manage an effective anticoagulation therapy program, including a CD-ROM with practical forms, real-life examples, and other tools you can customize to your own organization.
Listen-on-Demand Audio Conference
Medication Management: NPSG on Anticoagulant Therapy
All health care organizations need to understand the likelihood of patient harm associated with the use of anticoagulation therapy. Join JCR Medication Management Practice Leader, Jeannell Mansur, R.Ph., Pharm.D., FASHP as she explains the expectations and requirements associated with this National Patient Safety Goal, and further addresses the policies and procedures organizations should have in place to ensure this Goal is being met.
Conference
The Joint Commission Annual Conference on Quality and Safety
Preconference: The 2009 National Patient Safety Goals
November 19, 2008
At this preconference you will hear an overview of The Joint Commission's National Patient Safety Goals (NPSGs) and related requirements, discuss current expectations in meeting these requirements and challenges, and learn strategies for implementing both the current and the new 2009 goals and requirements.
Medication Safety Consulting Services
Medication Safety consulting service
Our service helps organizations design and implement processes for meeting NPSG 3E. Our consultants are experts in all aspects of medication safety including storing, transporting, dispensing, and reconciling. All of JCR's medication safety consultants are pharmacists with many years of piratical experience.
For more information, please call 630.268.7400 or email ConsultingServices@jcrinc.com.
Articles
Deficits in Discharge Documentation in Patients Transferred to Rehabilitation Facilities on Anticoagulation: Results of a Systemwide Evaluation
Saint Joseph Health Care Anticoagulant Safety: Meeting the Challenges of Standard MM.6.20
Model Implementation Plan for Meeting NPSG 3E: Anticoagulation Therapy
Reducing Anticoagulant Medication Adverse Events and Avoidable Patient Harm
A Visual Medication Schedule to Improve Anticoagulation Control: A Randomized, Controlled Trial