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.