HospitalInspections.org

Based on a review of the Hospital Internal Investigation regarding a Coumadin (medication that delays blood clotting that is dosed based on the results of periodic blood coagulation tests called international normalized ratios [INRs] and is generally administered in the evening) ordering error involving Patient #2 and interviews, it was determined that the Hospital had not yet finished its investigation/analysis of the error.

Findings include:

The Hospital reported a Coumadin ordering error involving Patient #2 that occurred on 5/18/12 and contributed to a bleeding episode that occurred on 5/19/12. The Report indicated that Patient #2 had an extensive cardiovascular history and was taking Coumadin and 2 antiplatelet medications (medications that hinder blood clotting). On 5/18/12, Patient #2 had a cardiac defibrillator (an electrical device that applies countershocks to the heart in the event of life-threatening cardiac arrhythmia) implanted in the Electrophysiology (EP) Lab. The operative site was treated with thrombin (a substance that stops bleeding) and covered with a pressure dressing (to prevent bleeding). There was concern for bleeding into the operative site and EP Fellow #1 (a physician) notified a member of Patient #2's Cardiology Service Team that Patient #2 was not to be administered Coumadin that evening. Later that day, Cardiology Intern #1 contacted the EP Service regarding the administration of Patient #2's Coumadin and EP Fellow #2 indicated that the Coumadin could be administered. Based on a morning INR of 2.6 and a target INR of 2.5-3.5 [the theraputic range established for the patient based on the medical condition], Cardiology Intern #1 ordered 10 milligrams of Coumadin for Patient #2. The Coumadin was administered and on the morning of 5/19/12, Patient #2's INR was 3.9. On 5/19/12 at 5:00 P.M., Patient #2's INR was 5.4 and he/she was noted to have a hematoma (a mass of clotted blood) at the defibrillator implantation site. Patient #2 was provided with appropriate treatment interventions for the bleeding and his/her surgical site remained stable. Patient #2's Coumadin therapy was resumed on 5/22/12 and he/she was discharged home on 5/23/12.

A review of the Hospital Internal Investigation related to the Coumadin ordering error on 6/13/12 and 6/14/12 indicated that a Preliminary Investigation was conducted and a Root Cause Analysis Meeting was scheduled for 6/20/12. The Preliminary Investigation determined that: 1.) the error occurred secondary to physician communication issues, 2.) Patient #2 did not utilize the Hospital's Anticoagulation Management Clinic and Cardiology Intern #1 did not have information related to his/her Coumadin dosing prior to 5/16/12 and 3.) Cardiology Intern #1 ordered the 5/18/12 Coumadin dose based on the doses administered to Patient #2 on 5/16/12 and 5/17/12.

As of 6/14/12, the the Hospital had not finished its investigation/analysis of the Coumadin ordering error.

Based on a review of the Hospital Internal Investigation regarding a Coumadin (medication that delays blood clotting) ordering error involving Patient #2 and interviews, it was determined that the Hospital had not yet finished its investigation/analysis of the error and a Corrective Action Plan was therefore not developed and implemented.

Findings include:

Please see Tag A 287 for information regarding the Coumadin ordering error and the Hospital Internal Investigation/analysis of the error.

As of 6/14/12, the the Hospital had not finished its investigation/analysis of the Coumadin ordering error and a Corrective Action Plan was therefore not developed and implemented.