Case Study: Coumadin Controversy

David Rogers, a retired machinist, moved into the Sunset by theSea continuing care re-tirement community in 2012 with his wife,Daniella. Daniella had fallen and had difficulty walking on herown.

In September 2014, during a seven-day stay in the hospital,Rogers was diagnosed with abnormal heart rhythms and givenCoumadin, a popular blood thinner that could help reduce the riskof stroke. Both the hospital and Rogers’s doctor instructed thelong-term care community to give him a specific test to assess hisclotting rate, but the test was never done. Instead, the staff gavehim a test intended for patients taking heparin, a different bloodthinner.

During early October, staff members made notes in Rogers’s chartabout bruising on his body. One entry noted a large bruise on hisstomach that was purple in the center and green and yellow on theoutside. The nurses reasoned that the bruises must have come fromthe lift used in transferring him.

Rogers was brought to the emergency room after midnight onOctober 15 because of bleeding from his gums. At the emergencyroom, a test showed that his clotting rate was so slow that hemight never stop bleeding on his own. The doctor found Rogers’sbruises so severe and unusual that she asked the hospital tophotograph them. Desiree, Rogers’s daughter, remarked that thenurses must have noticed the bruising and asked why they failed todo something about it.

At the hospital, doctors gave Rogers vitamin K in an attempt tocounteract the Coumadin, but Rogers grew agitated and confused andhad difficulty breathing. Rogers’s daughter grew troubled by thelack of improvement and asked the doctor if there was any hope. Thedoctor said, “He’s weak, but we are doing all we can.”

As Rogers’s condition worsened, his wife became ill as well.Daniella was taken to the same hospital, and the family moved thetwo to the same room so they could be together. Rogers was mostlyunresponsive when he was brought into the room. But when the staffplaced Daniella’s hand in his, he woke up and was able tospeak.

Rogers died the next morning. Daniella passed away three weekslater. “After Dad passed away,” Desiree said, “she gave up.”

Case Study Questions

1. Describe the event briefly. What safety technique could be usedto investigate this event? Discuss the key contributory factorsthat led to this event.
2. What was the impact of this medical error on Mr. Rogers’ wifeand family?