Patient Safety Analysis Quick Reference Guides

Centers for Disease Control and Prevention

These quick reference guides were created to help you understand, modify, and interpret your data using the NHSN application’s various analysis output (report) options for the NHSN Patient Safety Component. These guides serve as companions to the “Introduction to NHSN Analysis” training slide set.

Managing the Risks of Direct Oral Anticoagulants

The Joint Commission: Sentinel Event Alert

While DOACs offer ease of use to patients, stopping bleeding events in patients on DOACs is more complicated, requiring 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. Also, some DOACs have no FDA-approved reversal agent at this time. Therefore, bleeding complications can be severe if these patients are not assessed according to guidelines on the management of DOACs. Intracranial hemorrhage is the most serious emergent bleeding risk.

In response to an increase in adverse events related to these widely prescribed medications, this alert provides guidance on the safe use and management of DOACs to all medical practitioners and health care organization leaders, particularly chief medical officers, pharmacists, emergency department clinicians, and quality and safety officers.

Anticoagulation FORUM: Numerous Resources and Expert Guidance

Anticoagulation FORUM

  • Education & Guidance
  • Webinars and Events
  • Centers of Excellence
  • Anticoagulation Stewardship

Established more than 25 years ago, the Anticoagulation Forum is the largest organization of its kind helping practitioners improve patient care by providing current and relevant information on best practices. The flagship program, the Anticoagulation Centers of Excellence, embodies our commitment to the clinical application of evidence-based practices and improved patient outcomes. Expert Guidance is provided by the Board of Directors, who are regularly relied upon for their expert opinion. Their contributions to research and guideline development have influenced all aspects of anticoagulation therapy.

Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement

Agency for Healthcare Research and Quality (AHRQ)

Pulmonary embolism resulting from deep vein thrombosis—collectively referred to as venous thromboembolism—is the most common preventable cause of hospital death. Pharmacologic methods to prevent venous thromboembolism are safe, effective, cost-effective, and advocated by authoritative guidelines, yet large prospective studies continue to demonstrate that these preventive methods are significantly underused. Based on quality improvement initiatives undertaken at the University of California, San Diego Medical Center and Emory University Hospitals, this guide assists quality improvement practitioners in leading an effort to improve prevention of one of the most important problems facing hospitalized patients, hospital-acquired venous thromboembolism.