Question

Case Study: Coumadin Controversy

David Rogers, a retired machinist, moved into the Sunset by the Sea continuing care re-tirement community in 2012 with his wife, Daniella. Daniella had fallen and had difficulty walking on her own.

In September 2014, during a seven-day stay in the hospital, Rogers was diagnosed with abnormal heart rhythms and given Coumadin, a popular blood thinner that could help reduce the risk of stroke. Both the hospital and Rogers’s doctor instructed the long-term care community to give him a specific test to assess his clotting rate, but the test was never done. Instead, the staff gave him a test intended for patients taking heparin, a different blood thinner.

During early October, staff members made notes in Rogers’s chart about bruising on his body. One entry noted a large bruise on his stomach that was purple in the center and green and yellow on the outside. The nurses reasoned that the bruises must have come from the lift used in transferring him.

Rogers was brought to the emergency room after midnight on October 15 because of bleeding from his gums. At the emergency room, a test showed that his clotting rate was so slow that he might never stop bleeding on his own. The doctor found Rogers’s bruises so severe and unusual that she asked the hospital to photograph them. Desiree, Rogers’s daughter, remarked that the nurses must have noticed the bruising and asked why they failed to do something about it.

At the hospital, doctors gave Rogers vitamin K in an attempt to counteract the Coumadin, but Rogers grew agitated and confused and had difficulty breathing. Rogers’s daughter grew troubled by the lack of improvement and asked the doctor if there was any hope. The doctor said, “He’s weak, but we are doing all we can.”

As Rogers’s condition worsened, his wife became ill as well. Daniella was taken to the same hospital, and the family moved the two to the same room so they could be together. Rogers was mostly unresponsive when he was brought into the room. But when the staff placed Daniella’s hand in his, he woke up and was able to speak.

Rogers died the next morning. Daniella passed away three weeks later. “After Dad passed away,” Desiree said, “she gave up.”

Case Study Questions

1. Describe the event briefly. What safety technique could be used to investigate this event? Discuss the key contributory factors that led to this event.
2. What was the impact of this medical error on Mr. Rogers’ wife and family?

Answer 1

1) Intially, there was noe done by longteem care community to do specific test to assess clothing late. They didn't monitor the clotting eate Coumadin has a navow therapeutic lange So, Determine the INR daily aftee administeation of intial dose until INR desutte stabilze in therepcite eange. The Frequency of peefoeming INR should be based on clerical situation but generally acceptable intervals toe INR defèeminations are 1 to 4 weeks Since full anticoagulation effect of coumadin se not achieved for several days. hepacin is peefereed foe intal eapid antcoagulation As heparin may affect the INR, patients leceiving both cacin and coumadin should have INR maritioning. It needed, apt7, PT should also be done. During early octobee , staff members made notre in Rogee's chart about bwising on his body but they usoned that the beuises must have come from dift used in teansfering him. → They didn't Assessed that beuises were due csto a oveedose of wae faein. де, CamScanner

Aftee midnight on Oct is There-bleeding from his gums. Later a test was done d it showed that his clotting state was so slao that he might neuke stop bleeding on his Day - Latee doctor gave Rogees- Vit-k in an attempt to - countract the Coumadin. Howevee The anticoagulant effect of coumadin peesiste beyond 24 hours & full anticoagulant effect is not achieved for several days' There wue several medical ecoes present in this patent case : Fustly, there was no specific monitoring test was done for the Coumadin dose monitoring Adverse effecte manitseing - dung intructor montseing And there were protheombin complex concentrate, Fresh frozen plasma , activated Factoe vi treatment may be considered if requirement to levere the effecti of Coumadin is regent Due to above medical ecoss, Rogers condition worsened and was fatal . It impacted on his wife · Became of the above medical elede we can say i Daniella wol in gelato loss of hee-family CamScanner