Standards FAQ Details | Joint Commission
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Friday 3:44 CST, February 12, 2016

Standards FAQ Details


National Patient Safety Goals (NPSG) (Critical Access Hospitals / Critical Access Hospitals)

Anticoagulation Therapy - NPSG - Goal 3 - 03.05.01
Revised | December 09, 2008

Prophylactic treatment

Q. Does NPSG.03.05.01 apply to prophylactic treatment?  At our hospital we often use therapeutic doses of heparin as an infusion for DVT prophylaxis after orthopedic surgery.

A. NPSG.03.05.01 applies to those situations when anticoagulant is administered therapeutically and not prophylactically regardless of the medication type (warfarin, heparin, low molecular weight heparin, etc.). However if it is usual practice for patients to be kept on therapeutic ranges of anticoagulant for several days as a prophylactic strategy then NPSG.03.05.01 is applicable.


Heparin for subcutaneous administration and line flushes

Q. Does NPSG.03.05.01 include anticoagulant drugs that are not used for therapeutic purposes, such as line maintenance? What about subcutaneous heparin?
A. No, the requirement only applies to patient’s receiving “anticoagulation therapy”. Thus, it only applies to patients receiving these drugs for therapeutic purposes, and not for flushes, etc. 


No dispensing or administration

Q. How does NPSG.03.05.01 relate to my organization if we do not dispense or administer anticoagulants?  Sometimes we will monitor or provide education on anticoagulation therapy, but we do not administer anticoagulants.
A. For the purposes of NPSG.03.05.01 “providing anticoagulation therapy” means dispensing or administering anticoagulants. If you do not dispense or administer anticoagulants then the requirement does not apply to your organization. Additionally, NPSG.03.05.01 does not apply for those organizations that are only monitoring (i.e. drawing labs and assessing for bleeding) or providing education on anticoagulation therapy. 


Anticoagulants subject to NPSG.03.05.01

Q. What anticoagulants are included under NPSG.03.05.01?
A. The only anticoagulant drugs included currently under the requirement are warfarin, unfractionated heparin, and low molecular weight heparins. Eventually, other anticoagulants may be added to the list in the future. However, there is nothing that prevents an organization from including any other anticoagulant in their management program starting in 2009. Such an approach is encouraged but not required. 


Program definition

Q. For EP 1, what is meant by a “defined anticoagulant management program”?
A. The term “defined anticoagulant management program” means a program, specified in writing, for individualizing anticoagulation therapy for each patient that involves the use of standardized practices and patient involvement, and which is specifically designed to reduce the risk of adverse drug events associated with the use of heparin (unfractionated), low molecular weight heparin (LMWH), warfarin, and other anticoagulants.