Common Mistakes

The Joint Commissions Sentinel Event Database includes 446 medication-related sentinel events (unexpected occurrences involving death or serious injury) reported from January 1997 through December 2007. Of those events, 32 (7.2% of total) involved anticoagulants. Causes of these events were the following:

The Joint Commission has stated one contributing factor to some of these sentinel events was the lack of standardization for the naming, labeling and packaging of anticoagulants, which causes confusion. Fresenius Kabi USA, LLC supports the standardization of anticoagulant labeling and packaging and has taken a major step in reducing medication errors through the enhanced labeling of its heparin products.