Deviation in the Standard of Medical Care When Caring for a Patient on Coumadin (Warfarin)

Evaluate breaches in the standard of care when evaluating a Deviation in the Standard of Medical Care When Caring for a Patient on Coumadin (Warfarin)

Answer the following questions to find out if the standard of care was followed for your case.

  • Was the patient’s need for coumadin therapy documented?
    Yes
    No
    Answer unknown
    Antithrombotic therapy suppresses the natural hemostatic mechanisms and is effective for preventing and treating venous, cardiac, and arterial thromboembolism.
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  • Was a physical examination performed? Why is this important?
    Answer this question
    A complete medical history and carefully focused physical examination serve as the core of the diagnostic process. The information obtained guides the further direction of the patient's evaluation and enables the clinician to make the most judicious use of additional tests. It helps determine the value of incongruent and conflicting results that can emerge during the diagnostic process, and it can obviate the need for tests that are costly or expose the patient to discomfort or risk. The deep understanding of the patient that can be obtained only through the immediacy of the history and physical examination also plays a pivotal role in treatment decisions that must be addressed at various points throughout the patient's lifetime.
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  • Were diagnostic laboratory studies obtained? Why is this important?
    Answer this question
    Routine laboratory studies can provide important clues to diagnosis.
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  • Was a coagulation profile obtained prior to anti-coagulation therapy? Why is this important?
    Answer this question
    When starting any oral anticoagulants, an initial international normalized ratio (INR), needs to be obtained, documented in the patient’s chart, and monitored throughout therapy.
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  • Did the patient have any contra-indications to anti-coagulation? Why is this important?
    Answer this question
    Coumadin is contra-indicated in patients who are pregnant. Coumadin must be used with extreme caution in the elderly, in children, in patients with a history of ulcers, esophageal varices, stroke, TIA, or coagulopathy since they are particularly sensitive to the medication.
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  • Was the patient hospitalized? Why is this important?
    Answer this question
    Therapeutic anti-coagulation is used to treat patients with a highly suspected or confirmed diagnosis of DVT or pulmonary embolism.
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  • Was prophylactic oral anti-coagulant therapy initiated for patients at risk? Why is this important?
    Answer this question
    Coumadin therapy is beneficial for patients with increased risk factors of thromboembolism.
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  • Was the patient’s coumadin therapy routinely monitored? Why is this important?
    Answer this question
    Long term monitoring of oral anti-coagulant therapy by assessing the INR level is essential to the safety of the patient.
    (2000) 109 AMJLME 6 481

  • Was the coumadin dose adjusted to keep the INR level within therapeutic range? Why is this important?
    Answer this question
    The reduction or withholding of a single dose or an increase in that day's dose is often sufficient to restore a therapeutic international normalized ratio in a patient who is otherwise medically stable.
    (2000) 109 AMJLME 6 481

  • Which of the following signs and symptoms did the patient experience? Why is this important?
    Answer this question
    Frequently, the first sign of an unstable INR is increased bruising. The most common sites for bleeding in patients treated with anticoagulants are the gums, the gastrointestinal tract, genitourinary tract, and soft tissues.
    (2008) 26 ECARDC 2 157

  • Were diagnostic laboratory studies performed? Why is this important?
    Answer this question
    In patients with active bleeding, it is necessary to perform a full coagulation screen, a complete blood count, to evaluate the INR, and to evaluate hepatic and renal function studies.
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  • Which type of bleeding did the patient experience? Why is this important?
    Answer this question
    As the international normalized ratio rises, the risk of hemorrhage also rises. Non-life threatening bleeding needs to be managed to prevent any serious seqeulae.
    (2000) 109 AMJLME 6 481

  • Did the patient require a surgery? Why is this important?
    Answer this question
    Reversal of oral anticoagulant therapy - withholding coumadin, administering vitamin k, and/or administering prothrombin complex concentrate infusions, may be required in the event the patient requires emergency surgery, extensive dental work, or invasive procedures.
    (2010) 28 ESURGO 6 243-247

  • Was health education provided regarding coumadin therapy? Why is this important?
    Answer this question
    Coumadin therapy must not be discontinued until the patient has been advised by the healthcare provider as serious consequences may occur.
    (2001) 85 EMEDCN 5 1109

  • Was the patient initially started on a therapy combination of a heparin infusion and oral coumadin? Why is this important?
    Answer this question
    Coumadin usually takes five days to become fully effective. It is for this reason that, a heparin infusion is begun in conjunction with the oral coumadin regimen.
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  • Did the patient receive education regarding INR monitoring and coumadin dosage? Why is this important?
    Answer this question
    Coumadin doses may be adjusted to achieve a therapeutic INR level. A patient’s thorough understanding of the importance for frequent INR evaluations and possible dose adjustments will improve compliance and ultimately improve the therapy outcome.
    (2000) 109 AMJLME 6 481

  • Which of the following methods were used to reverse the anti-coagulation? Why is this important?
    Answer this question
    As the international normalized ratio rises, the risk of hemorrhage also rises. Non-life threatening bleeding needs to be managed to prevent serious seqeulae.
    (2000) 109 AMJLME 6 481

  • Was the patient’s INR monitored after the coumadin reversal? Why is this important?
    Answer this question
    After corrective therapy has been initiated, the INR needs to be monitored at frequent intervals to achieve homeostasis and to prevent the formation of any thrombosis.
    (2000) 109 AMJLME 6 481

  • Which of the following measures were taken prior to a surgical procedure? Why is this important?
    Answer this question
    For elective surgery coumadin needs to be discontinued for 1 or 2 days prior to the procedure and then restarted on the evening after the procedure.
    (2001) 85 EMEDCN 5 1109