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[Closed Claim Study] Failure to communicate and to properly administer warfarin


In November 2010, an 80-year-old man moved into an assisted living facility. He had a pacemaker and a history of three cerebrovascular accidents (CVAs). The patient’s medications included daily warfarin, which required daily international normalized ratio (INR) checks.


The facility employed an outside home health care vendor to provide care for its residents. Employees of the facility regularly administered medication to residents, based on the vendor’s orders.


Upon the patient’s admission, a family medicine physician employed by the vendor became the patient’s physician. This physician typically communicated her medication orders first to the home health vendor. The home health vendor would then inform the facility, and facility employees would administer medication to her patients.


Physician Action

On March 30, 2011, the patient’s INR level was measured as low. The family physician sent an order to the health care vendor to increase the patient’s warfarin dosage to 3 mg per day and to recheck the INR in three days. The vendor communicated this order to the facility. The facility misinterpreted the order as being to discontinue the warfarin in three days.


On April 2, the patient’s INR levels were again too low. The family physician gave a phone order to an advanced practice provider (APP) from the health care vendor to continue warfarin at 3 mg daily and to check the INR levels on April 4. The APP never communicated this order to the facility.


On April 4, the family physician gave another phone order to the same APP to increase the warfarin to 5 mg daily and to repeat the INR check on April 7.


On April 7, the patient had an acute embolic CVA after not receiving warfarin for at least one week. On this same day, the APP documented the April 4 phone order.


The patient died a few months later.



The patient’s family filed a lawsuit against the family physician, the APP, the health care vendor, and the assisted living facility. The lawsuit alleged that the failure to timely and correctly administer warfarin caused the patient’s CVA and death.


Legal implications

Experts for the plaintiff were critical of the care provided to this patient. One of the experts was critical of the family physician for not taking the appropriate steps to ensure the providers received her orders. This expert also noted that the APP failed to conduct a telephone read back with the family physician of the April 2 warfarin order and then failed to deliver the order to the facility.


The facility was also criticized for failing to accurately transcribe the orders they received on March 30 from the vendor. The facility also failed to document when the patient received warfarin.


These actions were all deemed by the plaintiff’s expert as breaches to the standard of care that caused the patient’s acute embolic CVA and eventual death. Another expert for the plaintiff argued that the family physician should have ordered the use of heparin when the patient’s INR continued to fall.


Family physician and geriatrics consultants for TMLT were more supportive of the defendant family physician. They both felt that the outcome of this case was primarily due to a system failure by the staff members of the health care vendor, including the APP, and the assisted living facility. The geriatrics consultant felt this patient should have been in a nursing home, as opposed to an assisted living facility, where he would have received more appropriate care for his condition.



Due to the administrative errors and miscommunication that resulted in the death of the patient, this case was settled on behalf of the family physician. The cases against the APP, health care vendor, and assisted living facility were also settled with the plaintiff.


Risk management considerations

Effective communication between physicians and staff members is critical for quality patient care. This case demonstrates a communication breakdown between all parties involved. In this scenario, physician orders for medication, lab studies, tests, procedures, and follow-up appointments with the facility’s residents should have been documented using a well-maintained system to ensure that clear, consistent communication existed between the four entities involved (physician, patient, care vendor, and facility administrators).


Every practice requires a process to ensure physician orders are received, reviewed, and acted upon in a timely manner. These processes ensure quality continuity of care. Maintaining and following written policies and procedures for patient care can help ensure that each staff member understands his or her responsibilities. When training materials or process guidelines are developed or updated, it is helpful to have staff members sign and date the materials or guidelines as acknowledgment that they have read and understand the policies and responsibilities of every staff member.


Another weakness in this case was the lack of clear, comprehensive, and contemporaneous documentation. From the notes maintained by the assisted living facility, it was unclear if the patient received any of the medication ordered by the family physician. There is also no record of the patient requesting his medication, which brings up questions of how clear the family physician was with the patient on what medications were ordered and required for his continued care.


Follow up care can be improved by recruiting and engaging patients in their own care. Had the family physician discussed her rationale for increasing the warfarin dosage with the patient, the patient may have better understood his care needs and become more active in seeking treatment from the facility.


It is also important to immediately document phone calls, including any instructions received for patient care or instructions given out to patients. This is critical, as it may become difficult to remember a phone discussion over time or what instructions or orders were given. In addition to facilitating continued quality care, comprehensive and up-to-date documentation can become valuable in defending a medical liability claim.


Wayne Wenske can be reached at