Inadequate INR monitoring implicated in woman's death.
A 59-YEAR-OLD WOMAN was diagnosed with atrial fibrillation and heart failure by a cardiologist and put on warfarin, which the cardiologist discontinued after a few days. Warfarin was resumed when the patient underwent surgery to place a mechanical heart valve.
The patient's international normalized ratio (INR) was tested daily while she was in the hospital, and warfarin was stopped several times. She was discharged with a prescription for 2 mg warfarin because her INR was 2.2, below the therapeutic range.
At a follow-up visit, the cardiologist checked the INR, which was 3.1. He saw the patient in the office again 8 days later, and 6 days after that a call was made to him, but no further blood tests were performed.
Eight days after the call, the patient was found unresponsive, with indications of gastrointestinal (GI) bleeding, and taken to the emergency department. Her INR level was at least 24.4, the highest the equipment could measure. In addition to GI bleeding, she had bleeding in her lungs. She died the next day.
PLAINTIFF'S CLAIM The defendants didn't monitor INR properly; the doctor knew the importance of monitoring INR while the patient was taking warfarin.
THE DEFENSE The INR level was normal at the posthospital visit. That measurement, along with the monitoring done while the patient was hospitalized, was appropriate monitoring. The patient died of sepsis, not exsanguination.
VERDICT $386,648 net California verdict.
COMMENT This could have happened to any of us. If you monitor warfarin in your practice, make sure the follow-up system is water tight.
Use a registry and double checking system. Be sure you know who is responsible during care transitions.
COMMENTARY PROVIDED BY John Hickner, MD, MSc
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|Title Annotation:||WHAT'S THE VERDICT; international normalized ratio|
|Publication:||Journal of Family Practice|
|Article Type:||Brief article|
|Date:||Feb 1, 2013|
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