Planning for National Patient Safety Goal 3E

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Planning for National Patient Safety Goal 3E

• Reduce the Likelihood of Patient Harm Associated
  With the Use of Anticoagulant Therapy

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National Patient Safety Goal 3E

• Overview of Joint Commission patient safety
  initiative.
• National Patient Safety Goal 3E.
• Implementation time line
• Implementation expectations
• NPSG 3E implementation and the medical staff.

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Joint Commissions National Patient Safety Goals

• Purposepromote specific improvements in patient
  safety.
• Highlight problem areas and describe (prescribe)
  solutions.
• Goals, requirements, implementation expectations
  recommended to Joint Commission Board by expert
  Advisory Group.
• Compliance assessed via on-site surveys and
  Periodic Performance Review.
• Failure to comply can lead to loss of
  accreditation
• Recognizing that sound system design is
  intrinsic to the delivery of safe, high quality
  health care, the goals generally focus on
  system-wide solutions whenever possible

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• National Patient Safety Goal 3E
• Reduce the likelihood of patient harm associated
  with the use of anticoagulation therapy
• Applies only to organizations that provide
  anticoagulation therapy

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Rationale for NPSG 3E

• Anticoagulation is a high risk treatment, which
  commonly leads to adverse drug events due to the
  complexity of dosing these medications,
  monitoring their effects, and ensuring patient
  compliance with outpatient therapy.
• The use of standardized practices that include
  patient involvement can reduce the risk of
  adverse drug events associated with the use of
  heparin (unfractionated), low molecular weight
  heparin (LMWH), warfarin, and other
  anticoagulants.

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NPSG 3E Phase-In

• One year phase in period that includes
• Defined expectations for planning, development
  and testing (milestones) at 3. 6, and 9 months in
  2008
• Expectation of full implementation by January 2009

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NPSG 3E Implementation TimelineMilestones

• 4/1/08 Organization leadership assigns
  responsibility for oversight and coordination of
• Development
• Testing
• Implementation
• 7/1/08 Implementation work plan in place that
  identifies
• Adequate resources
• Assigned accountabilities
• Time line for full implementation
• 10/1/08 Pilot testing in at least one clinical
  unit is underway
• 1/1/09 Process fully implemented across the
  organization

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Components of NPSG 3E

• A 1. The organization implements a defined
  anticoagulant management program to individualize
  the care provided to each patient receiving
  anticoagulant therapy.
• A 2. To reduce compounding and labeling errors,
  the organization uses ONLY oral unit dose
  products and pre-mixed infusions, when these
  products are available.
• C 3. When pharmacy services are provided by the
  organization, warfarin is dispensed to each
  patient in accordance with established monitoring
  procedures.

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Components of NPSG 3E (2)

• C 4. The organization uses approved protocols
  for the initiation and maintenance of
  anticoagulation therapy appropriate to the
  medication used, to the condition being treated,
  and to the potential for drug interactions.
• C 5. For patients being started on warfarin, a
  baseline International Normalized Ratio (INR) is
  available, and for all patients receiving
  warfarin therapy, a current INR is available and
  is used to monitor and adjust therapy.
• C 6. When dietary services are provided by the
  organization, the service is notified of all
  patients receiving warfarin and responds
  according to its established food/drug
  interaction program.

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Components of NPSG 3E (3)

• A 7. When heparin is administered intravenously
  and continuously, the organization uses
  programmable infusion pumps.
• C 8. The organization has a policy that
  addresses baseline and ongoing laboratory tests
  that are required for heparin and low molecular
  weight heparin therapies.
• C 9. The organization provides education
  regarding anticoagulation therapy to staff,
  patients, and families.

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Components of NPSG 3E (4)

• C 10. Patient/family education includes the
  importance of follow-up monitoring, compliance
  issues, dietary restrictions, and potential for
  adverse drug reactions and interactions.
• A11. The organization evaluates anticoagulation
  safety practices.

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NPSG 3E in a nutshell

• Policy Process Protocols
• Processes and/or protocols must be used for all
  patients receiving anticoagulants heparin,
  LMWH, warfarin, direct thrombin inhibitors.
• These protocols must be individualized to meet
  patient individuality (age/weight/co
  morbidities), address each medication, the
  condition being treated and any potential for
  drug-drug interactions.

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NPSG 3E in a nutshell

• Dispensing and Administration
• Pharmacy dispenses only premade IV and unit dose
  formulations when possible
• Programmable infusion pumps are utilized.
• Dietary notification process in Drug/Food
  Interaction Program
• Appropriate labs baseline and monitoring are
  done on all patients receiving anticoagulants
• Establish monitoring procedures in concordance
  with dispensing of anticoagulants labs done and
  reviewed and documented before dispensing.

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NPSG 3E in a nutshell

• Education
• Education on Anticoagulation and Process is done
  for all staff
• MD, RN, Pharmacy
• Patient and Family
• Education provided for all patients being
  discharged on anticoagulants includes follow-up
  monitoring, compliance, dietary restrictions and
  potential for adverse events.

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NPSG 3E in a nutshell

• Evaluation and Audits
• Both Process and Results will be evaluated
• All anticoagulation safety practices are
  evaluated
• Examples
• of INR above 6
• of INR above therapeutic range
• Time to achieve therapeutic INR
• of patients with baseline labs ordered
• of patients receiving anticoagulants on
  approved protocols

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Implementation Overview
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Medical Staff

• Medical staff participation in developing
  organization-wide policies
• Organization-wide defined anticoagulant
  management program
• Organization evaluates anticoagulation safety
  practices
• Organization provides education to staff
  (including physicians) as well as patient/family

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Medical Staff

• Consensus medical staff-approved policies
  addressing at a minimum
• Approved protocols for initiation and maintenance
  of anticoagulation therapy
• Warfarin--Baseline INR, current INR available and
  is used to monitor and adjust therapy (implied
  policy)
• Heparin/LMWHPolicy addresses baseline and
  ongoing laboratory tests
• Warfarin dispensed to each patient in accordance
  with established monitoring procedures
• Virtually every aspect of anticoagulation
  treatment is incorporated in this standard.

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Medical Staff

• Other required policies/protocols/procedures to
  be approved by medical staff
• Only oral unit dose products and premixed
  infusions to be used
• Dietary services notified of all warfarin
  patients and responds according to established
  food/drug interaction program
• Patient/family education is provided regarding
  anticoagulation therapy (certain topics are
  specified)

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Medical Staff

• Decision to anticoagulate remains with the
  treating physician.
• Anticoagulant management, including monitoring,
  will be through use of peer-developed and
  approved consensus protocols.
• Decisions to opt out of protocols will require
  documentation and explanation.
• Deviations from protocols will require
  documentation and explanation.
• Processes and results will be reviewed regularly.

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QA