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Search results for "Organizational Policy/Guidelines"
- Organizational Policy/Guidelines
Journal Article > Commentary
Delivery of optimized inpatient anticoagulation therapy: consensus statement from the Anticoagulation Forum.
Nutescu EA, Wittkowsky AK, Burnett A, Merli GJ, Ansell JE, Garcia DA. Ann Pharmacother. 2013;47:714-724.
Anticoagulant medications are considered among the highest-risk medications in common use, due to the potential for serious bleeding complications if medication errors occur. As a result, ensuring anticoagulant safety is one of the National Patient Safety Goals. This consensus statement provides guidelines for developing safer systems for the appropriate prescribing, administration, and monitoring of anticoagulant drugs in the hospital setting, as well as for minimizing adverse events after hospital discharge in patients receiving these medications. A serious medication error due to incorrect dosing of warfarin is discussed in an AHRQ WebM&M commentary.
Medication errors in acute cardiovascular and stroke patients. A scientific statement from the American Heart Association.
Michaels AD, Spinler SA, Leeper B, et al; American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology, Council on Quality of Care and Outcomes Research, Council on Cardiopulmonary, Critical Care, Perioperative, and Resuscitation, Council on Cardiovascular Nursing, Stroke Council. Circulation. 2010;121:1664-1682.
Patients hospitalized with acute coronary syndromes or strokes are particularly vulnerable to medication errors, as many of these patients are elderly, have complex medication regimens, or are administered high-risk medications such as anticoagulants. This position paper from the American Heart Association reviews the specific types of medication errors in these patients, including dosing errors, administration of contraindicated medications, and errors of omission (failure to prescribe recommended therapies). The authors make specific, evidence-based recommendations for preventing medication errors in this patient population, including integrating pharmacists into inpatient teams and using computerized provider order entry and medication reconciliation to detect and prevent errors. A medication error in an acute coronary syndrome patient is illustrated in this AHRQ WebM&M commentary.
Legislation/Regulation > Sentinel Event Alerts
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.
Legislation/Regulation > Multi-use Website
Oakbrook Terrace, IL: The Joint Commission; 2018.
The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety and preventing hospital-acquired infections, medication errors, and specific clinical harms such as falls and pressure ulcers. The 2019 NPSGs include two significant revisions. Hospitals and behavioral health facilities now must maintain specific protocols to prevent inpatient suicide, including conducting environmental risk assessments, screening patients admitted for behavioral health reasons for suicide risk, and implementing tailored suicide prevention plans for high-risk patients. The NPSG on ensuring the safety of anticoagulant medications has also been updated to incorporate new evidence in this area.
Recommendations from the British Committee for Standards in Haematology and National Patient Safety Agency.
Baglin TP, Cousins D, Keeling DM, Perry DJ, Watson HG. Br J Haematol. 2006;136:26-29.
The authors provide guidelines to help manage risks and ensure the safe administration of oral anticoagulant therapy in the United Kingdom.