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
, 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
, 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
. 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.
Free full text
Anticoagulant safety practices call for pharmacist supervision.
Scott A. Drug Topics (Health-System Edition). November 10, 2008.
Intravenous infusion safety technology: return on investment.
Danello SH, Maddox RR, Schaack GJ. Hosp Pharm. 2009;44:680-687, 696.
Improving heparin safety: a multidisciplinary invited conference.
Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.
Cause for concern: drug shortages disrupt operations, tax hospitalists' treatment patterns.
Collins TR. The Hospitalist. July 2011.
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