Delay in administering anticoagulant

‍by Rachel Pollock, Marketing and Brand Specialist, and
‍Karen Werth, MBA, CPHRM, Senior Risk Management Representative

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Presentation

A 75-year-old woman was admitted to a rehabilitation hospital after experiencing weakness and an increased number of falls at home. The patient had a history of coronary artery disease, congestive heart failure, sick sinus syndrome (SSS), and long-time use of anticoagulation and antiplatelet medications. The hospital documented her medications as rivaroxaban and/or warfarin to treat atrial fibrillation. She was also taking clopidogrel as an antiplatelet. After 15 days, she was discharged.
 
Approximately one year later, on July 16, the patient was re-admitted to the rehabilitation hospital following a series of falls. Information about her medications was provided to the hospital by the patient’s spouse and home health nurse two days before admission.

Physician action

Upon admission, the attending hospitalist conducted a physical exam and reviewed the patient’s history. He documented his findings in the hospital’s electronic health record (EHR). The EHR included a section for medications that pre-populated her medications before the exam was conducted. The listed active medications did not include any anticoagulant or antiplatelet drugs. 
 
The physician noted that the patient “had increasing weakness over the past several weeks associated with atrial fibrillation.” His notes also indicated that the patient had multiple issues that required close monitoring including chronic obstructive pulmonary disease, congestive heart failure, back pain, spinal stenosis, and recent falls. 

Daily progress notes showed that the patient’s atrial fibrillation was well controlled. On July 21, the patient experienced an episode of hallucinations but was otherwise alert and oriented. The hospitalist ordered the administration of clopidogrel, and the patient received her first dose on July 22.
 
On July 23, the patient began to exhibit weakness and impaired movement. The patient had a stroke that evening.
 
She was transferred in critical condition to a nearby hospital. A head CT showed an occlusion of the M2 segment of the left middle cerebral artery. The patient also exhibited altered mental status, inability to speak, and focal weakness on the right side. She died in the hospital two days later. 
 

Allegations

The patient’s family filed a lawsuit against the hospitalist. The allegations included failure to prescribe an oral anticoagulant and an antiplatelet medication which led to the patient’s injuries and death. 
 

Legal implications

An expert consultant for the plaintiff stated that the hospitalist breached the standard of care when he failed to review the patient’s history and medication profile and compare it to what was reported by the patient’s spouse and home health nurse on July 16. He failed to reconcile medications and prescribe anticoagulants to prevent stroke in a patient with atrial fibrillation.  
 
Defense consultants were also critical of the physician’s care of the patient. One consultant noted the lack of documentation, stating that the hospitalist should have noted the significant medication discrepancy in the patient’s medication records. 
 
Another consultant for the defense stated that it would have been appropriate for the hospitalist to document or question the omitted anticoagulant and antiplatelet medications from the patient’s list of medications. This consultant added that the documentation also lacked reasoning for starting the clopidogrel, as there were no documented events that would prompt adding this medication.
 

Disposition

The case was settled on behalf of the hospitalist. 

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More on medication errors.
Risk management for hospitalists.