Coumadin Controversy
Case Study: Coumadin Controversy
David Rogers, a retired machinist, moved into the Sunset by the Sea continuing care retirement community in 2012 with his wife, Daniella. Daniella had fallen and had difficulty walking on her own. In September 2014, during a seven-day stay in the hospital, Rogers was diagnosed with abnormal heart rhythms and given Coumadin, a popular blood thinner that could help reduce the risk of stroke. Both the hospital and Rogers’s doctor instructed the long-term care community to give him a specific test to assess his clotting rate, but the test was never done. Instead, the staff gave him a test intended for patients taking heparin, a different blood thinner. During early October, staff members made notes in Rogers’s chart about bruising on his body. One entry noted a large bruise on his stomach that was purple in the center and green and yellow on the outside. The nurses reasoned that the bruises must have come from the lift used in transferring him. Rogers was brought to the emergency room after midnight on October 15 because of bleeding from his gums. At the emergency room, a test showed that his clotting rate was so slow that he might never stop bleeding on his own. The doctor found Rogers’s bruises so severe and unusual that she asked the hospital to photograph them. Desiree, Rogers’s daughter, remarked that the nurses must have noticed the bruising, and she asked why they failed to do something about it. At the hospital, doctors gave Rogers vitamin K in an attempt to counteract the Coumadin, but Rogers grew agitated and confused and had difficulty breathing. Rogers’s daughter grew troubled by the lack of improvement and asked the doctor if there was any hope. The doctor 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 the two to the same room so they could be together. Rogers was mostly unresponsive when he was brought into the room. But when the staff placed Daniella’s hand in his, he woke up and was able to speak. Rogers died the next morning. Daniella passed away three weeks later. “After Dad passed away,” Desiree said, “she gave up.”
Case Study Questions
1. Describe the event briefly. What safety technique could be used to investigate this event? Discuss the key contributory factors that led to this event.
2. What type of quality management and safety processes should have been in place to prevent this medical error? Provide a rationale for your interventions.
3. How will you know that care has improved at the nursing home and such events can be prevented in the future? Discuss measures that you will track to assess improvements.
4. What was the impact of this medical error on Mr. Rogers’s wife and family?
Collepals.com Plagiarism Free Papers
Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.
Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS
Why Hire Collepals.com writers to do your paper?
Quality- We are experienced and have access to ample research materials.
We write plagiarism Free Content
Confidential- We never share or sell your personal information to third parties.
Support-Chat with us today! We are always waiting to answer all your questions.
