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Preventing errors relating to commonly used anticoagulants.
Sentinel Event Alert. September 24, 2008;(41):1-4.
Anticoagulant therapies such as heparin and warfarin are considered
high-alert medications
, due to the high potential for patient harm if used improperly. They have been associated with adverse events in a variety of settings, including in
hospitalized patients
and
outpatients
, and ensuring the safety of patients receiving anticoagulants is a
National Patient Safety Goal
for 2008. This
sentinel event alert
issued by the Joint Commission discusses the root causes of anticoagulant-associated patient harm and recommends strategies for reducing errors, including implementation of a pharmacist-led
anticoagulation service
. Sentinel event alerts are intended to promote rapid implementation of patient safety strategies, and adherence to these recommendations is assessed on site visits by the Joint Commission.
PubMed citation
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Resource Type
Organizational Policy/Guidelines
Setting of Care
Hospitals
Target Audience
Health Care Providers
Health Care Executives and Administrators
Clinical Area
General Internal Medicine
Hospital Medicine
Hospital Pharmacy
Safety Target
Discontinuities, Gaps, and Hand-Off Problems
Medication Errors/Preventable Adverse Drug Events
Anticoagulants
Approach to Improving Safety
Patient Self-Management
Communication between Providers
Clinical Pharmacist Involvement
Automatic drug dispensers
Bar Coding and Radiofrequency ID Tagging
Computerized Provider Order Entry (CPOE)
Patient Education
Origin/Sponsor
United States of America