Anticoagulation Patient Safety Goal Compliance at a University Health System: Methods for Achieving the Goal

Abstract

Purpose Outline steps taken at a university teaching health system to meet The Joint Commission's (TJC's) National Patient Safety Goal (NPSG) for anticoagulation therapy. Description The aim of NPSG 3E (recently renumbered as 03.05.01) was to reduce the likelihood of patient harm associated with anticoagulation therapy. Full implementation of a management program for individualization of patient care was required by January 1, 2009. University Health System (UHS) has formed an anticoagulation safety committee consisting of nurses, dieticians, pharmacists, and physicians. Monthly meetings are held to assign projects and responsibilities and to report progress of ongoing tasks. Subcommittees involving selected members have been formed to conduct in-depth evaluations of specific agenda items. The committee has defined target anticoagulants, including unfractionated heparin, enoxaparin, dalteparin, argatroban, lepirudin, fondaparinux, and warfarin. Current practice has been evaluated by gathering baseline adverse events data, performing drug utilization reviews, and analyzing usage. A timeline of progress and expected completion dates for each milestone has been created. Future tasks include developing standard protocols for all anticoagulants and ensuring consistency in discharge counseling. Recently, UHS created a new anticoagulation clinical pharmacist position, and a long-term goal is creation of an anticoagulation team. Responsibilities of this team will include therapy management, discharge counseling, staff education, and maintenance of evidence-based protocols. Conclusion Implementing a program of this caliber to meet TJC's January 2009 deadline for full implementation of a management program posed a challenge to this large teaching institution. This article outlines the steps necessary for ensuring achievement of milestone deadlines.