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.