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Medical Legal News
A free newsletter from Patricia Iyer MSN RN LNCC CLNI
Legal Nurse Consultant 908-788-8227
Who we are.
A Double Edged Sword
Since 1989, Med LeagueSupport Services, Inc. has
infarction, stroke, and limb gangrene.
administration of anticoagulants, such as
newborn twins of actor Dennis Quaid.
Med League Support
slows clotting time, fell on the ice and hit
tions can save lives, but also kill.
his head. Bleeding began within his brain,
causing death. The patient’s attorney filed
Patricia Iyer, MSN,
RN, LNCC, CLNI
intramuscular injections to a patient who
Past President of the
therapeutic values, the injections caused
of Legal Nurse
tion of blood in her right buttock. This in
administered incorrectly or in error.
turn pressed on the sciatic nerve, causing
a foot drop. The patient’s son, who was
Medical Legal News
claim and settled the case.
• The clotting time of a woman rose while she was on
anticoagulant use, notifying the dietary department of the
Heparin. When her hemoglobin began to drop, indicating
fact the patient is on Coumadin, using programmable
she was bleeding, the physician delayed ordering blood
infusion pumps and premixed infusions of Heparin, moni-
transfusions. The patient died from blood loss. A wrongful
toring bleeding time with INR (international normalized
ratio) levels, and education of staff, patients, prescribers,and families, among others. 6 This goal affects all Joint
What makes anticoagulants so dangerous? First,
there is a narrow therapeutic window of safety in the useof these medications. The primary action of anticoagu-
Analysis of Medical Records
lants, to increase bleeding time, can lead to hemorrhage at
Med League assists attorneys evaluating cases involv-
any site in the body. There are multiple food and drug
ing anticoagulant therapy by considering the answers to
interactions with anticoagulants, making the response to
these top ten questions and others applicable to the case:
these drugs unpredictable. Frequent monitoring of clotting
1.Was the patient an appropriate candidate for
time is necessary, requiring painful and frequent blood
tests. Even when this monitoring occurs, the level of
2. Did the patient comply with outpatient blood tests
anticoagulation is outside the therapeutic range almost half
needed to monitor response to the anticoagulants?
of the time. The risk of major bleeding with long-term
3. Were standardized protocols used to order
treatment increases in the elderly - the population most in
need of Coumadin for treatment of atrial fibrillation. These
risks dissuade many prescribers from using Coumadin. It
5. Were abnormally elevated clotting times acted upon
is estimated that Coumadin is not given to almost half of
6. Were there any signs of bleeding while the patient was
Given all of the dangers associated with these high-
risk drugs, anticoagulants are a primary focus of patient
7. How quickly did the healthcare team respond to
safety efforts. A few days after the news of the massive
overdoses received by the Quaid twins, Baxter an-
8. Did the nurses give Heparin or Coumadin as ordered?
nounced it had designed a new enhanced label that
9. Is there evidence that hemorrhage was the cause of the
featured an increase of 20% font size, a unique color
patient’s death, or was some other cause more likely?
combination, and a large red cautionary tear off label. 5 As
10. What type of medical expert is most appropriate toreview the case?
part of the 5 Million Lives Campaign of the The Institutefor Healthcare Improvement (IHI), a goal has been set toreduce harm 50% from high-alert medications by Decem-ber 2008. IHI directs attention to the high risk aspects of
these medications through seminars and extensive infor-
Med League helps to identify and prepare the types of
mation on their website, www.ihi.org.
demonstrative evidence most useful to identify the details
The Joint Commission (formerly the Joint Commis-
of the case. For example, in the case involving the he-
sion on Accreditation of Healthcare Organizations or
matoma that developed from multiple intramuscular injec-
JCAHO), which accredits most hospitals and a vast
tions, we did a timeline of key events in the days leading up
variety of other healthcare organizations, has identified a
to the hematoma diagnosis, a chart showing all of the
2008 National Patient Safety Goal related to anticoagu-
injections given in each buttock, and several line graphs
lants: “Reduce the likelihood of patient harm associated
correlating the clotting times, medications, and the injec-
with the use of anticoagulant therapy.” There is a one year
tions given each day. Demonstrative evidence is individual-
phase-in program with specific milestones set at 3, 6, and
ized to the details and themes of the case. Call us to discuss
9 months with the expectation that hospitals will fully
implement this goal by January 2009. The implementationprocess addresses several key components of medical,
References are found on our website at www.medleague.com/articles/
pharmaceutical, and nursing practice. These include use
index.html. This article was written by Pat Iyer MSN RN LNCC CLNI
of approved protocols for ordering and monitoring
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(Rev. Esp. Anestesiol. Reanim. 2005; 52: 109-114) CASO CLÍNICO Tratamiento con radiofrecuencia pulsada en dos casos de neuralgiaglosofaríngea idiopática y secundaria. Resultados preliminaresD. Abejón*, S. García del Valle**, C. Nieto*, C. Delgado***, J. I. Gómez-Arnau****Área de Anestesia, Reanimación y Cuidados Críticos. Unidad de Dolor. Fundación Hospital Alcorcón. Alcorcón. Madr