Patient Safety

Anticoagulation Management Program

By January 1, 2009 some hospitals, outpatient clinics, long-term care facilities and home care organizations accredited by the Joint Commission must perform nine elements of performance for the safety requirement "reduce the likelihood of harm associated with the use of anticoagulant therapy." The requirement is known as National Patient Safety Goal 3E.

The nine elements of performance, as defined by The Joint Commission, are:

  1. AnticoagulationThe hospital/organization implements a defined anticoagulation management program to individualize the care provided to each resident receiving anticoagulant therapy.
  2. To reduce compounding and labeling errors, the hospital/organization uses only oral unit dose products, pre-filled syringes, or pre-mixed infusion bags when these types of products are available. For pediatric patients/residents, pre-loaded syringe products should only be used if specifically designed for children.
  3. The hospital/organization uses approved protocols for the initiation and maintenance of anticoagulant therapy appropriate to the medication used, to the condition being treated, and to the potential for medication interactions.
  4. For patients/residents starting on warfarin, a baseline International Normalized Ratio (INR) is available, and for all patients/residents receiving warfarin therapy, a current INR is available and is used to monitor and adjust this therapy.
  5. When dietary services are provided by the hospital/organization, the service is notified of all patients/residents receiving warfarin and responds according to its established food/medication interaction program.
  6. When heparin is administered intravenously and continuously, the hospital/organization uses programmable infusion pumps in order to provide consistent and accurate dosing.
  7. The hospital/organization has a written policy that addresses baseline and ongoing laboratory tests that are required for heparin and low molecular weight heparin therapies.
  8. The hospital/organization provides education regarding anticoagulation therapy to staff, residents and families. Patient/resident and family education includes the importance of follow-up monitoring, compliance issues, dietary restrictions, and potential for adverse drug reactions and interactions.
  9. The hospital/organization evaluates its anticoagulation safety practices, takes appropriate action to improve its practices, and measures the effectiveness of those actions on a regular basis.

In September 2008, the Joint Commission provided Suggestions for Preventing Errors with Anticoagulant Drugs:

For all anticoagulants:

  • AnticoagulationPerform an organizational-wide risk assessment for anticoagulant therapy.
  • Use best practices or evidence-based guidelines regarding the use of anticoagulants.
  • Establish organization-wide dose limits on anticoagulants and screen all orders for exceptions (i.e., require a confirmatory override by the physician).
  • Clearly label or otherwise differentiate syringes and other containers used for anticoagulant drugs.
  • Clarify all anticoagulant dosing for pediatric patients.
  • Promptly re-evaluate patients whose anticoagulant is being held for a procedure. The re-evaluation should include an assessment of the need to reorder anticoagulant therapy.
  • Hospitals and ambulatory facilities should provide timely communication of all anticoagulant-associated lab values to the provider or the person managing the anticoagulation therapy.
  • Under the supervision of clinical staff, educate and assist inpatients who require anticoagulant drugs to practice administering their own medications. This will help reduce the risk of errors after discharge.

For heparin:

  • AnticoagulationConsolidate and limit the number of institutional unfractionated heparin dosing nomograms. For all heparin medication orders (inpatient and outpatient), require prescribers to include the calculated dose and the dose per weight (e.g. milligrams per kilogram) or body surface area to facilitate an independent double-check of the calculation by a pharmacist, nurse or both. For morbidly obese patients, the standard nomograms may not be accurate.
  • Before the start of a heparin infusion and with each change of the container or rate of infusion, require an independent double check of the drug, concentration, dose calculation, rate of infusion, pump settings, line attachment and patient identity.
  • Use heparin flush only for central lines and eliminate heparin flush of peripheral intravenous lines. Stock and use only pre-filled syringes commercially prepared at set unit doses for flush solutions.
  • Identify patients with heparin-induced antibodies and heparin-induced thrombocytopenia (HIT) to avoid life-threatening events from heparin exposure.
  • Dispense only preservative-free heparin to neonates and build an alert to pharmacists with this directive into order systems.