Cardiology Expert Opines on Negligent Administration of Multiple Anticoagulant Drugs

Case Overview

This case involves a patient who presented to the hospital with acute shortness of breath. The patient was given a screening test for blood clotting and subsequently put on an anticoagulant. After identifying a blot clot in the patient’s leg, cardiologists ordered an additional anticoagulant to be administered, and for the patient to be checked six hours later. However, the anticoagulant was not checked as ordered. Eventually, a coagulation panel indicated elevated INR levels and the patient was given a third anticoagulant. The Cardiology service’s plan was to discontinue the second coagulant for two hours and continue the third. Although the third was discontinued, the second drip was left running.

Although critical care medicine had been consulted earlier in the hospitalization, they showed up many hours later. An additional ordered coagulation panel was not performed until the next day. Following this, several coagulation panels were performed. At some point in the charting, it was noted that second coagulant was reduced and then restarted at a much higher dose. Cardiology recommended the two anticoagulants be continued, but another physician simultaneously ordered the second anticoagulant to be discontinued. A short time later, the patient was killed by an acute cranial bleed.

Questions to the Cardiology expert and their responses

How familiar are you with treating patients who present with similar complaints and associated coagulopathy?

I have extensive experience working with patients who are on anticoagulation. Based on the scenario presented, it appears there was a breakdown in the medical documentation, the orders/panel set, and question of the availability/ adherence to an anticoagulation protocol. With the given the severity of the patient's condition on initial presentation, it may have been appropriate for the patient to have been transferred to a hospital with a higher level of care much sooner.

What are appropriate medications/ dosages required to help reverse abnormal coagulation values?

The standard of care is to give FFP STAT in patients who present with elevated INRs. Vitamin K can be given as well. Whenever there is the presence of or concern for DIC, sepsis, or liver failure, other factors may be considered.

What would be considered proper steps or protocols in documenting orders, plan of care and/ or interventions?

In current practice, hospitals have standing or institutional anticoagulation protocols that are weight based and include detailed instructions on how much heparin to give immediately and subsequently, the timing of specific labs that need to be ordered, orders to notify the treating physician, and the necessary changes that can be made to the dosages of the medications. It is also important for the physician and nurse to document appropriately as well as have the lab results to help assess the situation.

About the expert

This expert has over a decade of experience in the field of cardiology and electrophysiology. He earned his BS from the Massachusetts Institute of Technology and his MD from the University of Michigan Medical School, before receiving his MS in translational research from the University of Pennsylvania School of Medicine. He then completed an internship and residency in internal medicine at the University of Texas Southwestern Medical Center, a prestigious fellowship in cardiology at the University of California, San Francisco, and a second prestigious fellowship in cardiac electrophysiology at the Johns Hopkins Hospital. Today, this expert is board certified in cardiovascular disease and clinical cardiac electrophysiology. He is a member of several professional organizations, including the Heart Rhythm Society, the American Heart Association, and the American College of Cardiology. He is also very active in academia, having published over 90 peer-reviewed journal articles and 12 book chapters on topics related to cardiology and electrophysiology. This expert previously served as the team cardiologist for the Philadelphia 76ers and as an instructor and then assistant professor of cardiology at the University of Pennsylvania. Currently, he is an associate professor of cardiology, a cardiologist in the department of athletics, and the director of the inherited arrhythmic disease center at an Ivy League university in Pennsylvania.

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Specialties:

Cardiology

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