2Purpose of National Patient Safety Goals (NPSG): Promote improvements in patient safetyHighlight problem areas in health careDescribe evidence-based solutionsFocus on system-wide solutionsThe purpose of the Joint Commission’s National Patient Safety Goals:to promote specific improvements in patient safetyhighlight problematic areas in health care and describe evidence and expert-based solutions to these problemsfocus on system-wide solutions, wherever possible.
3National Patient Safety Goals Goals and Requirements are developed by expertsApproved by the JC’s Board in June 2007Goals 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
4National Patient Safety Goal 3E: Anticoagulation Reduce the likelihood of patient harm with the use of anticoagulation (AC) therapy.Applies to multiple inpatient and outpatient settingsRationale: Anticoagulation therapy is a high risk treatmentRequirement: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.
5Risks with Anticoagulant Therapy Anticoagulants listed as one of the top 5 drug Classes with patient safety incidents¹Reported meds involved in harmful events²:#3 Heparin, #6 Warfarin, #9 EnoxaparinEnoxaparin medication related deaths reported to MedMarx in 2005²Heparin errors typically involve infusion pump and IVdelivery errors³Cousins D et al. 2006USP MedMarx data, 2005Fanikos J. et al. 2004Look alike products• Confusion between low molecular weight heparins (LMWHs) and unfractionated heparin (UFH)• Confusion between insulin and heparin
6National Patient Safety Goal 3E: Applies to the use of Heparin, low molecular weight heparins, warfarin and other anticoagulantsOne year phase-in period with full implementation by January 1, 2009.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.
7NPSG 3E – Timeline: April 1, 2008 - assigned coordination of NPSG 3E July 1, implementation work plan & timelineOctober 1, 2008, pilot testing in one unitJanuary 1, process fully implementedAs of April 1, 2008, assigned responsibility for oversight and coordination of NPSG 3EAs of July 1, 2008, an implementation work plan is in place that id’s resources, accountabilities and timeline for full implementationAs of October 1, 2008, pilot testing in at least one clinical unit is under wayAs of January 1, 2009, the process is fully implemented across the organization
8Surveying and Scoring NPSG’s: Evaluate actual performanceAll requirements must be implementedCompliant or Not CompliantFailure to comply will result in a “Requirement for Improvement (RFI)”Surveyors evaluate actual performance, not just intentAll requirements must be implementedNPSG requirements are Compliant or Not Compliant on a JCAHO surveyFailure to comply with a NPSG Requirement will result in a “Requirement for Improvement (RFI)”
9NPSG 3E: Anticoagulation For more information, see the Joint Commission Website:References:Cousins D et al Risk assessment of anticoagulation therapy. National Patient Safety Agency. United KingdomUSP MedMarx data, 2005Fanikos J. et al. Medication errors associated with anticoagulant therapy in the hospital. Am J Cardiol. 2004; 94: