PRACTICE PARTNER
PATIENT SAFETY
We use this forum to regularly report on findings from patient safety organizations, expert review
committees of the Office of the Chief Coroner, and inquests.
Long-Term Care
MDs must monitor
INR levels: Chief
Coroner Committee
P
hysicians working in long-term care
homes are reminded of the need for
regular and as needed monitoring of
the INR, especially when there is a
change in a patient’s health status.
The reminder stems from an investigation
conducted by a committee of the Chief Coro-
ner’s Office into the death of a 77-year-old
woman in a long-term care home (LTCH).
The resident, who was admitted to the
LTCH on December 1, 2015 had a known
diagnosis of atrial fibrillation and was on
warfarin with an initial admission INR within
the therapeutic range. No regular monitoring
of the INR was ordered by the physician nor
flagged by the staff or pharmacist.
The patient had difficulty settling into her
new environment and was eating poorly. She
was found to have a urinary tract infection and
in mid-December she was started on nitrofu-
rantoin. She became nauseated. No reassess-
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DIALOGUE ISSUE 2, 2019
ment of the INR was ordered.
She continued to fare poorly throughout
the month, including developing a respiratory
infection. She began vomiting on December
31st. She was vague, confused and incontinent
of stool in her bed. Staff noted large bruises on
her body. The registered nurse spoke with the
family who reported that the resident had peri-
ods of confusion, mumbling and withdrawing.
A note was made to continue monitoring the
resident and to have her assessed by a physician
the next time they were in the LTCH.
Later that day, the family asked for the pa-
tient to be transferred to the acute care hospi-
tal. The INR results could not be located in the
record.
On January 1, 2016, while in the acute
care hospital, investigations revealed that the
patient’s INR level was elevated at 10 (therapu-
etic range for atrial fibrillation is between 2-3).
The patient continued to fare poorly. On
Change in health status can
see levels increase