Alert Issued on Use of Blood Thinners
Anticoagulants, better known as blood thinners, were the target of an alert put out by the Joint Commission recently. Diane Cousins, vice president of the Advancement of Patient Safety of the US Pharmacopeia, stated that in the last seven years 70,000 medication errors have involved blood thinners with 26 resulting in death. Heparin and warfarin have been among the top ten offenders.
The new alert warns health professionals on heparin, warfarin and the drug enoxaparin .
When used properly and appropriately blood thinners can be life-saving agents and bring relief from various conditions like stroke. The difference between an excessive or insufficient dose, however, is tricky and can depend on many factors including drug-drug and drug-nutrient interactions. A little bit taken at the wrong time can fail to prevent the clotting problems the medication was intended for and a little bit too much can cause excessive bleeding and hemorrhage.
Medication errors were found by the Joint Commission to result from the inappropriate recording of a patient’s weight, to other issues such as distractions, high workload and inexperience.
In 2008 the Joint Commission listed recommendations in their alert which included:
• Screening patients for appropriateness of medication including the possibility of any interactions
• Standardization of how these anticoagulants are prescribed, labeled, packaged and delivered to the bedside including bedside administration
• Limits should be set on where the dose might be outside the usual ranges and unless a physician specifically orders that dosage, it should not be given
• Special consideration should be paid to babies and children. The elderly were not, but should have been, mentioned in this consideration because of their increased sensitivity to medications and tendency for polypharmacy use in this population
• Organizations should consider computerized physician ordering and use of bar coding.
The Joint Commission is a nonprofit organization that accredits more than 15,000 health care organizations across the U.S.
About the author
Kathy Shattler received her Master of Science degree from Michigan State University in E. Lansing Michigan in Human Nutrition. Her twenty-two years of practice includes holding positions as a Lecturer, Chief Clinical Dietitian and Program Manager. Kathy is the Founder of Nutri-Care Consulting and is currently the Nutrition Director of www.CEU4U.COM, an online continuing education management company for Registered Dietitians and Dietetic Technicians.
