Risk Management Tools & Resources


CASE STUDY: Numerous Lapses Lead to Medication Error and Subsequent Patient Death

Laura M. Cascella, MA

CASE STUDY: Numerous Lapses Lead to Medication Error and Subsequent Patient Death


The patient was a male in his early sixties who had undergone a total hip replacement and was discharged to a rehabilitation facility. The patient was prescribed warfarin postsurgery to prevent deep vein thrombosis (DVT). A few days after being admitted to the rehab facility, the patient dislocated his new hip and was readmitted to the hospital. An attempt at closed relocation of the hip was unsuccessful, so the patient was scheduled for a second surgery to implant a larger prosthetic joint.

Two days after the second surgery, the patient had a positive hemoccult test, and a gastroenterologist was called in for a consultation. The gastroenterologist recommended discontinuing warfarin and observing the patient's condition. The patient's primary care doctor, an internal medicine (IM) physician, recommended compression boots to reduce the risk of DVT in the absence of warfarin, but the patient refused to wear them. A limited Doppler ultrasound was performed on the patient's left leg; however, no further action was taken.

All physicians involved in the patient's care — the IM physician, the gastroenterologist, and the surgeon — agreed the patient should be started on dalteparin once he returned to the rehab facility. This recommendation was documented in the transfer orders, but the patient did not receive the medication upon return to the facility. Further, the IM physician and attending physician never spoke.

Five days later, the attending physician at the rehab facility reviewed the patient's chart and realized he had not taken any anticoagulants since the gastroenterologist discontinued the warfarin. The patient was started on dalteparin at that point. However, during a physical therapy session the following day, the patient became short of breath, fell, and later died. The autopsy determined that the cause of death was pulmonary embolism. The patient's family filed a malpractice lawsuit against the IM physician, the gastroenterologist, and the attending physician at the rehab center. The case ultimately was settled in the high range.


Various breakdowns in patient care and communication occurred in this case, which ultimately led to the patient's untimely death. One contributing factor to the poor outcome was clinical judgment — particularly inadequate patient assessment and failure to rule out abnormal findings. Experts involved in the case were critical of the IM physician for not following up after the limited Doppler ultrasound of the patient's left leg with either a better quality test or a vascular consultation. Additionally, despite the positive hemoccult test, none of the patient's physicians recommended an endoscopy to rule out internal bleeding — another decision questioned by the experts. Further complicating the situation, the patient's health record included no documentation related to these clinical decisions or the rationale for not doing additional testing.

Patient noncompliance was another issue in this case. Although the IM physician recommended that the patient wear compression boots to reduce his risk of DVT in the absence of taking anticoagulants, the patient refused. Although the patient's refusal was documented in his health record, the IM physician did not document any efforts to educate the patient (or his wife) about the importance of the compression boots and possible adverse outcomes from not following the recommendation. As a result, it's unclear whether adequate patient education occurred and whether the patient understood the possible consequences of noncompliance.

A number of issues also occurred in relation to the discharge process that complicated this case. First, all of the physicians treating the patient at the hospital agreed that the patient should be started on dalteparin. However, rather than starting the patient on the medication prior to discharge (to ensure he received it), they recommended he start taking it after returning to the rehab facility. This decision introduced uncertainty regarding who was responsible for ordering the medication; as a result, the recommendation fell through the cracks and the medication was not ordered.

Second, the aforementioned process breakdown was complicated by the fact that the IM physician — who was the patient's primary provider — and the attending physician at the rehab center never discussed the patient or his treatment plan. This lack of communication hindered the possibility that the prescribing oversight would be discovered in a timely manner.

Third, when the patient was transferred back to rehab, only a portion of his health record was received. This system glitch resulted in critical information about the patient's course of care and recommended treatment being unavailable to the rehab facility and attending physician.

Finally, communication issues between the patient/patient's wife and the providers were noted during the malpractice litigation. The patient's wife contended that the recommendation that the patient start on dalteparin was never communicated to them in the hospital. Thus, when the attending physician at the rehab facility discovered that the patient had not received anticoagulants for days and attempted to start the patient on the medication, the patient initially refused.

Although the patient eventually agreed to start the dalteparin after discussing DVT risks with the attending physician, he made clear that he also wanted to speak with the IM physician and the surgeon. The attending physician never followed up on this request or contacted any of the patient's other physicians to discuss his condition.

In Summary

This case highlights numerous areas of risk — clinical judgment, collaborative care, patient handoffs, and communication — that present persistent challenges for healthcare providers. In busy clinical environments, with multiple providers involved in patient care, the opportunities for oversights or errors are abundant. Standardization and well-developed processes can help address these issues.

Providers and healthcare organizations should assess current policies and protocols related to documentation (e.g., clinical rationale, decision-making, treatment recommendations, etc.), handoff procedures (e.g., required information, accountabilities, etc.), and patient follow-up after discharge to home or another facility. Periodic review of these policies with insight from the healthcare providers and staff involved can help identify gaps and opportunities for improvement.

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