Adult/Geri Legal Case


67 year old female was prescribed coumadin by Dr. Smith, her primary care doctor, in August 2013 for atrial fibrillation. She was told to return in two days after initially being started on coumadin to have her INR checked. When she returned the INR value was normal. She was told to return again in a week to check the INR value. When she returned to the clinic in a week to see Dr. Smith, the INR was not performed, although other lab tests were performed.

She did not have another INR performed until about two and one-half months later. When the she came in in mid-November 2013, Dr. Smith’s practice was temporarily being covered by Dr. Jones, one of his partners. Dr. Jones was also supervising a certified registered nurse practitioner, Nancy Rock.

The patient complained of bruising and dizziness and was seen by the certified registered nurse practitioner. An INR was drawn that revealed a value of 34.2. The certified registered nurse practitioner instructed the patient to not take the Coumadin for four days and to have the INR level rechecked on the fifth day. The certified registered nurse practitioner did not show the critical INR value to Dr Jones.

The patient returned to the office the next day with nausea and vomiting. She was also still bleeding from the site where her blood had been drawn the day before.

The certified registered nurse practitioner drew another INR, which was 44.8. The certified registered nurse practitioner showed the latest INR value to Dr. Jones and he instructed her to refer the decedent to a hematologist. An appointment was made with the hematologist the next day, but the patient was found unresponsive by a friend prior to the appointment.

She was taken by ambulance to an emergency room, where a CAT scan showed a subdural hematoma with a midline shift. She died soon after that.

  • Identify the defendants AND areas of negligence
  • Research and identify appropriate management of coumadin/INR levels
  • Reflect on this case and identify what you would have done differently as an advanced practice registered nurse.
  • What do you think the verdict was and why?

Adapted from Medical Malpractice Verdicts, Settlements & Experts; Lewis Laska, Editor, 901 Church St., Nashville, TN 37203-3411

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