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











Patient Safety Tip of the Week Archive


What’s New in the Patient Safety World Archive