national patient safety goal 3e: anticoagulation

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

National Patient Safety Goals

• Goals and Requirements are developed by experts

• Approved by the JC’s Board in June 2007

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

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. 20062. USP MedMarx data, 20053. Fanikos J. et al. 2004

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, 2009.

NPSG 3E – Timeline:

• April 1, 2008 - assigned coordination of NPSG 3E

• July 1, 2008 - implementation work plan & timeline

• October 1, 2008, pilot testing in one unit

• January 1, 2009 - process fully implemented

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)”

NPSG 3E: Anticoagulation

For more information, see the Joint Commission Website:www.jointcommission.org

References:

1. Cousins D et al. 2006. Risk assessment of anticoagulation therapy. National Patient Safety Agency. United Kingdom

2. USP MedMarx data, 20053. Fanikos J. et al. Medication errors associated with

anticoagulant therapy in the hospital. Am J Cardiol. 2004; 94: 532-5.

DVT/PE Prophylaxis

Procedure related risk DVT/PE

Level of Risk

Calf DVT Proximal DVT

Clinical PE

Fatal PE

Low 2% 0.4% 0.2% 0.002%

Moderate 10%-20% 2%-4% 1%-2% 0.1%-0.4%

High 20%-40% 4%-8% 2%-4% 0.4%-1%

Very High 40%-80% 10%-20% 4%-10% 0.2%-0.5%

ICSI: Venous Thromboembolism ProphylaxisFourth Edition/June 2007

Medical Condition Risk DVT

Condition Risk of DVT

General Medical 10%-26%

MI 17%-34%

Stroke 11%-75%

CHF 20%-40%

Medical ICU 35%-42%

Chest 2005; 128;958-969

Percent of Patients Receiving Appropriate DVT Prophylaxis

WoodwindsSt 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

WoodwindsSt Joseph’s

Total

Med

Surg

25%

50%

75%

WoodwindsSt Joseph’s

Audit Jan 2008