The Joint Commission releases a new sentinel event alert: Managing the risks of direct oral anticoagulants

August 12, 2019

Anticoagulants are the No. 2 top medication involved in adverse drug events leading to death or serious harm. Risks to patients on Direct Oral Anticoagulants (DOACs) can be avoided with timely and appropriate treatment. The Joint Commission has released a Sentinel Event Alert to help manage these risks.

While DOACs offer ease-of-use to patients, stopping bleeding events in patients on DOACs is more complicated and requires different strategies than those for patients on warfarin (Coumadin®) and heparin. Unlike the more widely available reversal agents for warfarin and heparin, reversal agents for DOACs are lesser known and may not be available in every care setting.

There are ten ways to be prepared to treat patients who are on DOACs, and all of them are included in the Sentinel Alert. A few examples include:

• Bleeding of patients on DOACs cannot be stopped in the same way as for patients on warfarin and heparin. Reversal agents for DOACs are not as well-known as those for warfarin and heparin and may not be available in all settings.
• Avoid therapeutic duplication. This is a risk because often providers are not as aware of this class of medications and patients are less likely to recognize that these drugs are anticoagulants.
• Educate patients and families about DOACs. Help patients understand their medication schedule, as well as potential for adverse drug reactions and ways to prevent them.

For a list of the DOACs and more ways to be prepared to treat patients on DOACs, see The Joint Commission Sentinel Alert.


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