Joint Commission Revised NPSG Addressing Anticoagulant Therapy, Effective July 1, 2019

PUBLISHED: Jul 2, 2019
Relevant to: Ambulatory Care, Critical Access Hospitals, Hospitals, Long Term Care

The Joint Commission’s National Patient Safety Goal (NPSG) 03.05.01 addressing the management of anticoagulant therapy has eight (8) new elements of performance that are effective July 1, 2019. NPSG.03.05.01 is applicable to critical access hospital, hospital, nursing care center and medical centers (accredited under the ambulatory healthcare program) accreditation programs.

NPSG.03.05.01 requires organizations to reduce the potential for patient harm associated with the use of anticoagulant therapy. As this NPSG is now effective, organization may want to review key requirements outlined in this goal:

  • An organization’s anticoagulant therapy approach should be based on approved protocols and evidence-based practice guidelines. These protocols/guidelines should specifically address:
  • How organizations will address reversal of anticoagulation and management of bleeding events that are related to anticoagulant medications.
  • How patients on oral anticoagulants will be managed in the perioperative area – including but not limited to use of bridging medications, timing dosing around stopping/restarting of an oral anticoagulant.
  • How anticoagulants are initiated and maintained, with specific consideration given to medication type, dosing, patient age, renal and liver function, drug-drug and drug-food interaction and other risk factors as applicable.
  • Organizations should have written policies that address what baseline and ongoing laboratory tests will be used to monitor/adjust anticoagulant therapy (warafin therapy should use INR, direct oral anticoagulant (DOAC) should use evidence-based practice guidelines).

Organizations should also note the following:

  • TJC has clarified that NPSG.03.05.01 only applies to organizations that initiate, manage and adjust dosage for anticoagulation medications; organizations that only monitor or provide education about anticoagulant medication do not need to meet this NPSG’s requirements.
  • NPSG 03.05.01 does not apply to the short-term, prophylactic use of anticoagulants for venous thromboembolism prevention (i.e., therapeutic doses of heparin as an infusion for DVT prophylaxis after orthopedic surgery or other short-term use related to procedures or hospitalization.)
  • NPSG 03.05.01 applies to all classes of anticoagulants except Antiplatelet Agents-GP IIb/IIIa inhibitors.

Included with today’s notice are example policies related to anticoagulation management.

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