Joint Commission Sentinel Alert: Blood Thinner Deaths and Overdoses

The Joint Commission has released a new Sentinel Alert that recommends 15 steps for preventing deaths due to errors in the administration of anticoagulants.

The recommendations include establishing best practices such as clearer medication packaging, better staff communication, and the use of bar code labeling and computerized physician orders.

The alert can be found here: http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_41.htm