On July 30, 2019, The Joint Commission (TJC) issued Sentinel Event Alert 61: Managing the risks of direct oral anticoagulants (“DOACs”). The alert may be found here. According to TJC, “anticoagulants have been named second of the top medications involved in error incidents causing death or serious harm.” Because there are not FDA-approved reversal agents for all DOACs, there can be severe bleeding complications where patients aren’t assessed in line with guidelines regarding the management of DOACs. The alert notes that intracranial hemorrhage can be the most severe risk and the patient safety concerns apply to all settings.
The alert provides that DOACs present different risks than heparin and warfarin and have different reveal mechanisms; a reversal mechanism that works for one DOAC may not work for another; perioperative assessment and communication are critical; and especially important is avoiding therapeutic duplication.
TJC recommends certain actions to protect patients on DOACs from the “potentially deadly consequences related to bleeding risks”, such as:
- Create name awareness for the different types of DOACs;
- Use evidence-based protocols and practice guidelines for drug initiation and maintenance, reversal of anticoagulation and management of bleeding events, and perioperative management;
- Have a written policy on the need for baseline and ongoing laboratory test to monitor and adjust anticoagulant therapy;
- Include the particular DOAC’s indications for use on the patient’s prescription, in the instructions for the patient, and in the electronic medical record;
- Address anticoagulation safety practices; and
- Provide education to patients and families specific to the anticoagulant medication prescribed.
TJC also released an infographic entitled 10 ways to be prepared to treat patients on direct oral anticoagulants, which may be found here.
Norton Rose Fulbright professionals are available to provide additional information regarding compliance with The Joint Commission accreditation requirements.