Patient is Killed by Coumadin Overdose

Case Overview

This case takes place in New Jersey and involves an elderly female patient with atrial fibrillation who was admitted to a skilled nursing facility. Diagnoses on admission were diabetes, Parkinson’s disease, and hypertension. Due to the patient’s atrial fibrillation, Coumadin was administered and an order for clotting tests and intensive observation was given as well. However, while the screening protocols were ordered by the attending physician, the order was not properly carried over by the nurse on duty, and as a result the patient was not properly tested. No notes mentioning the need for testing were written by the nurse on the routine treatment log for the dates in question, and that lack of testing apparently continued for the next few weeks. As a result, the patient overdosed on Coumadin, causing a gastrointestinal bleed that resulted in hypovolemic shock and death.

Questions to the Internal Medicine expert and their responses

Do you routinely treat patients like the one described in this case?

I have had over a thousand patients administered Coumadin for atrial fibrillation yet not one has had unmonitored treatment.

Have you ever had a patient develop this outcome?

None have had the complication of shock from Gastrointestinal bleeding as a result of weeks of Coumadin without monitoring.

Based on this brief summary of the case, do you believe this patient might have had a better outcome had the care rendered been different?

Clearly, the standard of care was not met in the proper administration of a potent blood thinner (Coumadin) and the patient's outcome would have been different had closer monitoring occurred. This is unusual in its nature as there appears to be clear disregard for the need for closer attention to the patient's medications and monitoring.

About the expert

This highly qualified and board certified Internal Medicine physician has over 18 years experience working in private practice. He is a member of the American Medical Association, the American College of Physicians and the American Society of Internal medicine. He has won multiple awards throughout his career including America's Top Doctor for three consecutive years. He is currently a physician at his own private practice as well as an attending internal medicine physician/hospitalist at several area hospitals.