The Joint Commission is adding new performance elements to its National Patient Safety Goals for anticoagulant therapy. They address “using approved protocols and evidenced-based guidelines, ongoing patient monitoring…and evaluating organizational safety practices and then taking actions to improve those practices.”

Regardless of whether your facility is accredited by The Joint Commission, their goals and rationale are some of the most focused patient safety guides available. Your facility can use National Patient Safety Goals as a bellwether for determining if your efforts will effectively reduce patient harm.

Some Oregon facilities have gone above and beyond the National Patient Safety Goals, “taking actions to improve” and strengthen their systems for safe anticoagulant use.

What You Can Do: Learning from Oregon Prevention Strategies

We looked to Oregon’s Patient Safety Reporting Program (PSRP) data for an example of how an Oregon facility used an event to identify opportunities to enhance The Joint Commission’s new anticoagulation therapy performance elements.

Event Summary: A patient on anticoagulation medication was admitted to the facility and a biopsy was ordered to determine the pathology of a serious issue. However, no order was placed to hold or discontinue the anticoagulants prior to the biopsy. Additionally, the patient’s lab work indicated that they were at increased risk of bleeding. These opportunities for a “good catch” were missed and the radiology providers were never aware that the patient was on an anticoagulant. The biopsy was performed and the patient experienced serious complications.

The review and analysis from this event revealed strong prevention strategies that may help your facility prevent these types of events.

Strategy: Create Simplified Chart Views for Essential Information

The event review and analysis revealed that it was easy for providers to miss important details in the complex pre-operative chart. The Joint Commission’s new performance elements require that facilities use “approved protocols and evidence-based practice guidelines for perioperative management of all patients on oral anticoagulants.” However, if providers do not know that a patient is on antithrombotic therapy, they cannot initiate the correct treatment protocol. Going beyond the performance element, this facility addressed the issue by creating a simplified chart view specifically for radiology.

Strategy: Enhance Existing Safety Communication Protocols

The event review and analysis also revealed that the facility’s process for high-risk biopsies did not include specific checks to identify whether the patient was on anticoagulants. The facility identified two opportunities to enhance their existing protocols to ensure safe use of anticoagulants.
First, the facility built in a clinical decision support (CDS) to identify patients on anticoagulants. CDS gives providers well-timed information, typically right where care is being given, that informs their patient care decisions (Agency for Healthcare Research and Quality).

Second, the facility added a step to their timeout procedure in the radiology unit to ask about anticoagulant use. Both of these changes create opportunities to prevent a potential adverse event at different points in a patient’s care process.

What You’ll Need

ISMP Medication Safety Self-Assessment for Antithrombotic Therapy
Regardless of accreditor, another way you can ensure your medication management system puts patient safety first is with this tool from the Institute for Safe Medication Practices (ISMP). The tool gives you a comprehensive way to review antithrombotic medication safety, find system weaknesses, and identify opportunities for improvement. The tool includes recommendations for screening patients for antithrombotic agents before invasive procedures and for instructing patients to inform their practitioners that they are on antithrombotic therapy.

What have you done to address this or similar safety risks? Share what you’ve learned in your organization and contribute to the ongoing learning about adverse events in Oregon through the Patient Safety Reporting Program.