Confusion over warfarin Rx ends badly
A 48-YEAR-OLD MAN who had suffered a patellar tendon rupture to the left knee underwent bilateral patellar tendon repair by an orthopedic surgeon; long leg cylinder casts were applied to both legs. The patient started taking 5 mg warfarin the following day.
Two days later he was transferred to a skilled nursing facility for physical therapy and warfarin adjustment and assigned a primary care physician. During his stay in the nursing facility, the patient’s blood tests never showed a therapeutic warfarin level. He saw the orthopedist, who prescribed 4 to 6 more weeks of warfarin therapy and scheduled a return appointment for 2 weeks later.
The day after the patient saw the orthopedist, his primary care physician increased the warfarin dose to 6 mg. When a blood test 3 days later showed a nontherapeutic level, she increased the dose to 7 mg.
Twelve days later, the leg casts were removed and knee immobilizers applied. The doctor who removed the casts recommended that the patient keep taking warfarin for at least 6 more weeks until removal of the knee immobilizers and the start of range of motion exercises. The patient was given a prescription to take to the skilled nursing facility to continue warfarin at the discretion of the primary care physician. That same day, the primary care doctor ordered by telephone that the patient continue to receive the same dose of warfarin.
The patient was discharged home 2 days later with orders for physical therapy and a blood draw for prothrombin time/international normalized ratio (INR). Physical therapy began 3 days before the blood draw was to be performed. The blood draw was actually done a day later than ordered and one day after the patient had taken his last dose of warfarin.
The home health nurse notified the orthopedist that the patient had taken his last dose of warfarin and faxed him the results of the blood test, showing an INR of 1.3. Six days later, the nurse contacted the orthopedist again about the exhausted warfarin supply. The orthopedist told the nurse to get in touch with the primary care physician who had followed the patient during his stay at the skilled nursing facility. The nurse left a voice-mail message on the phone of the primary care physician’s nurse. Twenty-five days later, the patient suffered an embolism in his main pulmonary artery and died.
PLAINTIFF’S CLAIM The home health agency and physicians were negligent in failing to properly monitor the patient’s warfarin therapy.
THE DEFENSE The home health nurse acted properly in contacting the doctor. The orthopedist claimed that he had no duty to monitor the patient’s warfarin therapy because that was the responsibility of an internist. The primary care physician claimed that she wasn’t responsible for monitoring the warfarin after the patient was discharged from the skilled nursing facility.
VERDICT $76,760.12 net California verdict against the primary care physician with confidential post-trial settlement. The orthopedist received a defense verdict.
COMMENT Another example of lack of coordination of care, noncompliance, and inadequate follow-up. Although we can only partially improve adherence, we should shoulder responsibility for coordinated care!