Failure to Monitor Coumadin Regimen Leads to Death

This case takes place in California and involves a male patient who was prescribed a daily dosage of Coumadin without specific follow-up for routine lab studies. Some weeks after beginning the Coumadin regimen, the patient presented to the defendant physician with complaints of bruising. While the patient was bleeding internally, no thorough workup was ordered to evaluate the patient – instead, he was promptly discharged. No lab studies were ordered by the evaluating physician. A few days later, the patient presented to the ER where he expired as a result of internal bleeding. His INR hadn’t been monitored and it is alleged that if it were, earlier intervention or discontinuation of the Coumadin regimen would have likely resulted in a far better outcome for the patient.

Question(s) For Expert Witness

1. Do you treat similar patients?

2. Based on summary, was there anything that could have been done to avoid the outcome? Please explain

Expert Witness Response E-024085

Monitoring of Warfarin therapy by obtaining laboratory testing (mainly the INR) is indicated and agreed upon by many professional societies, including ASH (American Society and Hematology), and is standard of care. My initial thoughts, without the ability to look at the patient's chart, are that routine monitoring of the patient's INR would likely have indicated a toxic dose of Warfarin, and the provider could have decreased the dose of this medication (per standard dosing guidelines) to prevent any bleeding sequelae, or even given an anecdote if required for bleeding, such as vitamin K or a prothrombin complex concentrate (PCC).