National Patient Safety Goal 3E: Anticoagulation
Purpose of National Patient Safety Goals (NPSG): Promote improvements in patient safety Highlight problem areas in health care Describe evidence-based solutions Focus on system-wide solutions The purpose of the Joint Commission’s National Patient Safety Goals: to promote specific improvements in patient safety highlight problematic areas in health care and describe evidence and expert-based solutions to these problems focus on system-wide solutions, wherever possible.
National Patient Safety Goals Goals and Requirements are developed by experts Approved by the JC’s Board in June 2007 Goals and Requirements: Are developed by experts including those involved in patient safety, system engineers, individuals with hands-on experience in Health Care and experts in related fields (Pharmaceuticals, IT, etc) Approved by the Joint Commission’s Board in June 20007
National Patient Safety Goal 3E: Anticoagulation Reduce the likelihood of patient harm with the use of anticoagulation (AC) therapy. Applies to multiple inpatient and outpatient settings Rationale: Anticoagulation therapy is a high risk treatment Requirement: Reduce the likelihood of patient harm associated with the use of anticoagulation (AC) therapy. Applies to:Ambulatory Care, Critical Access Hospital, Home Care, Hospital, Long Term Care, and Office- Based Surgery.Rationale: Anticoagulation is a high risk treatment (complexity of dosing, monitoring of effects, ensuring patient compliance) which commonly leads to Adverse drug events (ADE’s). Use of standardized practices with patient involvement can reduce the risk of ADE’s.
Risks with Anticoagulant Therapy Anticoagulants listed as one of the top 5 drug Classes with patient safety incidents¹ Reported meds involved in harmful events²: –#3 Heparin, #6 Warfarin, #9 Enoxaparin Enoxaparin medication related deaths reported to MedMarx in 2005² Heparin errors typically involve infusion pump and IVdelivery errors³ 1.Cousins D et al USP MedMarx data, Fanikos J. et al Look alike products Confusion between low molecular weight heparins (LMWHs) and unfractionated heparin (UFH) Confusion between insulin and heparin
National Patient Safety Goal 3E: Applies to the use of Heparin, low molecular weight heparins, warfarin and other anticoagulants One year phase-in period with full implementation by January 1, Applies to the use of Heparin (unfractionated), low molecular weight heparin (LMWH), warfarin and other anticoagulants (does not apply to prophylactic doses of heparin and LMWH) One year phase-in period at 3,6 and 9 months, with full implementation by January 1, 2009.
NPSG 3E – Timeline: April 1, assigned coordination of NPSG 3E July 1, implementation work plan & timeline October 1, 2008, pilot testing in one unit January 1, process fully implemented 1.As of April 1, 2008, assigned responsibility for oversight and coordination of NPSG 3E 2.As of July 1, 2008, an implementation work plan is in place that id’s resources, accountabilities and timeline for full implementation 3.As of October 1, 2008, pilot testing in at least one clinical unit is under way 4.As of January 1, 2009, the process is fully implemented across the organization
Surveying and Scoring NPSG’s: Evaluate actual performance All requirements must be implemented Compliant or Not Compliant Failure to comply will result in a “Requirement for Improvement (RFI)” Surveyors evaluate actual performance, not just intent All requirements must be implemented NPSG requirements are Compliant or Not Compliant on a JCAHO survey Failure to comply with a NPSG Requirement will result in a “Requirement for Improvement (RFI)”
NPSG 3E: Anticoagulation For more information, see the Joint Commission Website: References: 1.Cousins D et al Risk assessment of anticoagulation therapy. National Patient Safety Agency. United Kingdom 2.USP MedMarx data, Fanikos J. et al. Medication errors associated with anticoagulant therapy in the hospital. Am J Cardiol. 2004; 94:
Procedure related risk DVT/PE Level of Risk Calf DVTProximal DVT Clinical PE Fatal PE Low2%0.4%0.2%0.002% Moderate10%-20%2%-4%1%-2%0.1%- 0.4% High20%-40%4%-8%2%-4%0.4%-1% Very High40%-80%10%-20%4%-10%0.2%- 0.5% ICSI: Venous Thromboembolism Prophylaxis Fourth Edition/June 2007
Medical Condition Risk DVT ConditionRisk of DVT General Medical10%-26% MI17%-34% Stroke11%-75% CHF20%-40% Medical ICU35%-42% Chest 2005; 128;
Percent of Patients Receiving Appropriate DVT Prophylaxis Woodwinds St Joseph’s Total Med Surg 25% 50% 75% 54% 38% 66% 31% 45% 38% Audit Jan 2008
Percent of High Risk Patients 0n Appropriate DVT Prophylaxis Woodwinds St Joseph’s Total Med Surg 25% 50% 75% Woodwinds St Joseph’s Audit Jan 2008