Dr H, 53, an internist, and her nurse practitioner, Ms B, 45, had been working together for several years at a large practice affiliated with a hospital. The clinicians worked well together, and Dr H relied on Ms B to handle things in the office when she was needed at the hospital.
One of their patients was Mrs A, an 80-year-old widow who had numerous medical conditions, including chronic pulmonary emboli (for which she was taking warfarin), hypertension, coronary artery disease, congestive heart failure, chronic restrictive lung disease, chronic kidney disease, and severe osteoarthritis in her right hip. Despite her ailments, Mrs A was cheerful and upbeat, preferring to walk rather than use her wheelchair when possible.
When Mrs A first came to the practice, about a year ago, Dr H noted that the patient was able to clearly relay her medical problems, knew what medications she was on, and was able to understand her treatment. At the first appointment, the physician took a blood test to check Mrs A’s INR level and found it to be low, at 1.5. She called the patient the next day to increase her dose of warfarin.
The physician explained to Mrs A that her optimal INR level was 2.0 to 3.0 and that Dr H would increase or decrease the warfarin dose as necessary to keep the INR at the right level. This was not new information to Mrs A, as her previous physicians had modified her warfarin prescription numerous times over the years.
During the past year, the patient was seen frequently by both Dr H and Ms B and had her warfarin dosage modified at least five times by the clinicians.
In January, Mrs A had a short hospitalization, and at the time of discharge her dosage was increased to 5 milligrams of warfarin daily at bedtime. At her follow-up appointment a week later on a Thursday evening, she met with Dr H. The patient brought all of her medication with her, including the warfarin, and asked questions about them. The physician ordered a blood test that evening to check the patient’s INR level. A follow-up appointment was scheduled for two weeks later, in early February.
The blood work came back that night and revealed an elevated INR of 3.7. The physician knew she would be in the hospital the following day, so she emailed Ms B late that night, asking her to contact the patient and reduce the warfarin from 5 milligrams daily to 5 milligrams on Tuesday, Thursday, Saturday, and Sunday, and 4 milligrams on Monday, Wednesday, and Friday.
The next day, Friday, Ms B received the email from the physician and contacted the patient. She reached Mrs A by phone that afternoon and explained the new dosage. “From now on, you’ll be taking 4 milligrams on Monday, Wednesday, and Friday, and you’ll be taking 5 milligrams on Tuesday, Thursday, Saturday, and Sunday,” she told the patient. She asked Mrs A if she understood the directions, and the patient said that she did. Ms B asked the patient to repeat the directions, and Mrs A was able to do so.
After getting off the phone with the patient, Ms B called the prescription into the pharmacy and noted her conversation with the patient in the patient’s chart. She also emailed Dr H to advise her that the conversation had taken place. The follow-up appointment was left for the same date in February.
Although the prescription was called in on Friday, Mrs A did not pick it up until Monday. Two days later, the patient was admitted to the hospital with extremity weakness, shoulder pain, limited arm motion, and an inability to feel or move her legs. Her INR was 5.36 and increasing. She developed a spontaneous bleed on her spinal cord, causing paralysis of her lower extremities. Despite the best efforts at the hospital, Mrs A continued to decline over the next several months until she died. After her death, the patient’s daughter retained an attorney and sued Dr H and Ms B, alleging that they failed to properly communicate the dosage decrease and improperly monitored her warfarin levels, leading to her death.