The Joint Commission issues new report on revised National Patient Safety Goal to reduce harm from anticoagulants

Report provides rationale, references and evidence in development of updated goal Thursday, December 13 2018

Katie Looze Bronk
Corporate Communications
(OAKBROOK TERRACE, Illinois, December 13, 2018) – A rise in adverse drug events associated with direct oral anticoagulants (DOACs) has led The Joint Commission to revise its National Patient Safety Goal (NPSG) 03.05.01: Reduce the likelihood of patient harm associated with the use of anticoagulant therapy, effective July 1, 2019.1
To help organizations better understand and comply with the updated NPSG, The Joint Commission has released a new R3 Report, Issue 19: National Patient Safety Goal for anticoagulant therapy. The report provides in-depth rationale, references and evidence that The Joint Commission employed during the development of the revised requirement.
The NPSG will include eight elements of performance (EPs)—specific actions, processes or structures that must be implemented to achieve the NPSG—applicable to all Joint Commission-accredited hospitals, critical access hospitals, nursing care centers and medical centers (accredited under the ambulatory health care program). 
Health care organizations will be required to use approved protocols and evidence-based guidelines for the:
  • Initiation and maintenance of anticoagulant therapy 
  • Reversal of anticoagulation and management of bleeding events related to each anticoagulation medication 
  • Perioperative management of all patients on oral anticoagulants
In addition, organizations will need a written policy addressing the need for baseline and ongoing laboratory tests to monitor and adjust anticoagulant therapy, as well as provide education to patients and families specific to the anticoagulant medication prescribed. 
Changes to the NPSG come after extensive literature and public field reviews. The Joint Commission also obtained expert guidance from a technical advisory panel and standards review panel to gather feedback from clinicians, organizations and professional associations. 
The prepublication version of the NPSG is available on the Prepublication Standards section of The Joint Commission website until June 30, 2019. 
The Joint Commission established its NPSG program in 2002 to help its accredited organizations address specific areas of patient safety concern. 
Goals are specific to each health care provider segment that The Joint Commission accredits and certifies, including hospitals, critical access hospitals, behavioral health care organizations, home care services, laboratories, nursing care centers and ambulatory health care centers. The NPSGs address problematic patient safety issues ranging from surgical-site infections and central line-associated bloodstream infections to hand hygiene and patient falls.
Over the years, the NPSG program has helped the nation’s health care organizations reduce and even eliminate patient safety problems and tragic errors like deaths from mistaken injections of concentrated potassium chloride. 
Accredited organizations’ performance on NPSGs, based on valid clinical data submitted to The Joint Commission as an accreditation requirement, is available for each organization via its Quality Report at   

1Office of Disease Prevention and Health Promotion, “Section 5: Anticoagulants.” IN: National Action Plan for Adverse Drug Event Prevention. Rockville, MD: U.S. DHHS, ODPHP, 2014, 50-98.


About The Joint Commission
Founded in 1951, The Joint Commission seeks to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The Joint Commission accredits and certifies more than 21,000 health care organizations and programs in the United States. An independent, nonprofit organization, The Joint Commission is the nation’s oldest and largest standards-setting and accrediting body in health care. Learn more about The Joint Commission at



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