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WEDNESDAY, Sept. 24 (HealthDay News) -- In the wake of several high-profile medication errors, some of them fatal, involving widely used blood thinners, the Joint Commission has released an alert recommending strategies to reduce these errors.
The new alert focuses specifically on low-molecular weight heparin, warfarin and low-molecular weight enoxaparin.
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"Blood thinners, the informal name for anticoagulant medications, have caused serious harm in a variety of incidents over the years including, very recently, harm to babies and adults in very different settings across the country," Dr. Mark Chassin, president of the Joint Commission, said during a teleconference Wednesday.
"When used appropriately and safely, they are lifesaving and prevent very serious conditions like stroke," he continued.
Blood thinners are among the top five drug classes associated with patient safety problems in the United States.
"Anticoagulants are notoriously tricky drugs to manage," said Dr. Peter Angood, the commission's vice president and chief patient safety officer.
"The difference between an appropriate and lifesaving and an excessive or insufficient dose is very, very narrow," Chassin added. "A little bit too much can cause severe bleeding. A little bit too little can fail to prevent the clotting problems the medication was intended for."
According to Diane Cousins, vice president of the Center for the Advancement of Patient Safety, United States Pharmacopeia, in the last seven years, 70,000 medication errors have involved anticoagulants, with 26 resulting in death. Heparin and warfarin have consistently ranked among the 10 most frequently reported drugs. Three percent of these medication errors were harmful, compared to only 1.5 percent in the database overall.
Heparin, warfarin and enoxaparin were associated with the most errors.
The errors come in a variety of forms: Misplacement of a decimal point can result in a 10-fold overdose. In one case, a patient's weight was recorded as 130 kilograms instead of 130 pounds, resulting in a fatal overdose.
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