Page 15 - 2022 Risk Basics - Systems

SVMIC Risk Basics: Systems

indicate she was taking Coumadin along with Warfarin and aspirin
daily. There was no discussion of the recent labs.

Later that same evening, Mrs. Jones was taken to the ED with
complaints of vomiting and abdominal pain, with elevated WBC

and low RBCs (these values were higher than the upper threshold
capability of the hospital’s equipment). She was aggressively

treated but expired two days later, allegedly from Coumadin toxicity.
A medical malpractice lawsuit was filed.

Dr. Smith testified that when he was notified of the critical value,
he called the hospital lab technician and instructed her to have

Mrs. Jones discontinue her Coumadin. This was disputed by the

technician, and there was no telephone record indicating such
a call. Mrs. Jones’ family testified that they were not notified by
anyone of the result or told to discontinue the Coumadin.

Dr. Carter testified that he firmly believed neither he nor his NP

had a duty to monitor a medication prescribed and monitored by a
specialist, even after receiving the critical value lab report.

Each physician and NP are highly regarded within the healthcare

community, but this case illustrates a number of failures:

• Provider-to-provider communication breakdown

• Poor documentation

• Lack of medication reconciliation

• Failure to track and notify of test results

• Failure to document after-hours calls

• Inadequate patient education on medication side effects

Page 15