The Joint Commission issues new Sentinel Event Alert on managing risks of direct oral anticoagulants

Bleeding risks for patients on DOACs can be avoided with appropriate and timely treatment Tuesday, July 30 2019

Katie Looze Bronk
Corporate Communications

(OAKBROOK TERRACE, Illinois – July 30, 2019) – Anticoagulants – medications that keep blood from clotting – have been named the No. 2 top medications involved in error incidents causing death or serious harm. While direct oral anticoagulants (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. 

In response to an increase in adverse events related to these widely prescribed medications, The Joint Commission has published a new Sentinel Event Alert on managing the risks of DOACs. The alert provides guidance on 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. 

The alert stresses the importance of understanding risks, benefits, side effects and potential antidotes or reversal agents for all kinds of anticoagulants, and communicating this information as appropriate to patients, their families and caregivers. According to the alert, to avoid wrong interventions for patients taking DOACs, clinicians should be aware of how:

  • DOACs present different risks than warfarin and heparin and have different reversal mechanisms.
  • A reversal mechanism that works for one DOAC may not work for another. 
  • Perioperative assessment and communication are critical to assess bleeding risk. 

Safety actions outlined in the alert encourage health care organizations to:

  • Create name awareness for the various kinds of DOACs – particularly among pharmacists, emergency department clinicians and providers who may be called upon to rapidly reverse life-threatening bleeding.
  • Use evidence-based protocols and practice guidelines for drug initiation and maintenance, reversal of anticoagulation, and management of bleeding events and perioperative management.
  • Maintain a written policy on the need for baseline and ongoing laboratory tests to monitor and adjust anticoagulant therapy.
  • Include particular DOAC’s indications for use in the patient’s instructions, prescription and electronic medical record. 
  • Address anticoagulation safety practices by taking actions to improve and measure them, as well as to establish a process to identify, respond to and report adverse drug events. 
  • Provide education to patients, their families and caregivers specific to the anticoagulant prescribed.

The Joint Commission revised its National Patient Safety Goal (NPSG) on anticoagulation, effective July 1, 2019 for hospitals, critical access hospitals, nursing care centers and ambulatory care organizations that initiate, manage and adjust dosage for anticoagulation medications. The NPSG was revised to assist these organizations in designing systems of care to prevent quality and safety issues related to DOAC prescribing, monitoring and treatment of severe bleeding. 

The Sentinel Event Alert and accompanying infographic are available on The Joint Commission website. They may be reproduced if credited to The Joint Commission. 


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