Richard Cahill, JD, Vice President and Associate General Counsel, and Kathleen Stillwell, MPA/HSA, RN, Senior Patient Safety Risk Manager, The Doctors Company
Practitioners face potential liability when patients do not follow up as instructed or refuse at-home help. In the event a claim results, even a verdict decided in the practitioner’s favor does not negate the time, expense, reputational damage, adverse social media publicity, potential administrative investigations, or emotional toll created by a lawsuit.
An older adult with a history of obesity, hypertension, hypercholesterolemia, atrial fibrillation, and cardiovascular disease saw the same physician for 20 years. During one hospitalization, the patient was put on the anticoagulant Coumadin. The physician and the discharge nurse both educated the patient and the patient’s spouse about the risks of Coumadin use and the importance of having blood work done every month. The conversations were appropriately documented in the patient record.
The patient did not, however, keep the first monthly appointment to check the international normalized ratio (INR). The physician’s staff called to schedule a follow-up visit, but the patient did not return the call. Two days after the call, the patient fell at home and was taken to the emergency department. The patient’s spouse told the staff that, although they had missed the appointment for blood work, the patient had taken the Coumadin as prescribed. The patient’s INR was 8.8—an extremely elevated reading (the therapeutic range for individuals on Coumadin is generally 2 to 3).
The patient was diagnosed with a bilateral subdural hematoma and underwent a bilateral craniotomy. After being discharged home, secondary to problems with coordination and confusion, the patient presented to the emergency department several more times over the next few months.
The patient sued for medical malpractice, claiming that the physician failed to properly manage the medication regimen and monitor blood levels, resulting in the fall, subsequent injury, and poor recovery. The patient also claimed that the physician was negligent in providing warnings about the risk of bleeding when taking Coumadin.
The case went to trial after extensive discovery was conducted. Because of the thorough documentation, the jury agreed that the physician had properly educated the patient and made the appropriate resources available to monitor the effects of the Coumadin. The jury also found that the patient’s failure to schedule necessary lab appointments and then follow up with an in-office visit as instructed was the cause of the injury. Accordingly, a defense verdict was rendered in favor of the physician.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.