What’s New in the Patient Safety World
October 2008
Joint Commission Sentinel Event Alert on Hazards of Anticoagulation
The Joint Commission has released a new Sentinel Event Alert “Preventing errors relating to commonly used anticoagulants” This alert summarizes the sentinel events in the Joint Commission Sentinel Event Database related to anticoagulation and provides excellent discussion on contributing factors and risk reduction strategies.
Those of you who have been reading our columns for the past year have seen multiple discussions on the hazards of anticoagulation including Patient Safety Tips of the Week:
August 19, 2008 Arterial Line Issues
July 29, 2008 Heparin-Induced Thrombocytopenia
July 22, 2008 Lots New in the Anticoagulation Literature
July 15, 2008 Heparin Flushes.....Again!
July 17, 2007 Falls in Patients on Coumadin or Other Anticoagulants
And also the following “What’s New in the Patient Safety World” columns:
December 2007 What’s
Old is What’s New: 1000-fold heparin overdoses back in the news again
April 2008 More
Neonatal Incubator Fires, More on Nosocomial UTI’s, More on 1000-Fold Heparin
Overdoses
May 2008 UK
NPSA Alert on Heparin Flushes
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What’s New in the Patient Safety World Archive