Decompensation / focused change
F1 Bleeding with supratherapeutic INR | Anticoagulation-specific review of a patient on warfarin noted new ecchymoses on both forearms and a report of bleeding gums with brushing, with no melena, hematuria, or signs of major bleeding. Point-of-care INR 4.2, above the ordered range; vital signs stable. Findings indicate supratherapeutic anticoagulation with minor bleeding. Provider notified at 11:40 with the INR and the bleeding signs; order received to hold the next warfarin dose and recheck the INR in two days. Bleeding precautions, fall avoidance, vitamin-K dietary consistency, and interaction screening reinforced; the patient was instructed to seek emergency care for any sign of major bleeding or a head injury. Teach-back accurate. INR recheck and reassessment scheduled in two days. |
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F2 Subtherapeutic INR — thrombosis risk | Anticoagulation-specific review found a point-of-care INR of 1.4, below the ordered range, in a patient on warfarin; the patient reports a recent course of an interacting medication and some missed doses, and denies bleeding or thromboembolic symptoms. Findings indicate subtherapeutic anticoagulation with increased thrombosis risk. Provider notified at 10:50 with the INR, the adherence gap, and the interacting medication; order received to adjust the dose and recheck, and to review the interaction. Adherence, interaction avoidance, vitamin-K consistency, and symptoms of thrombosis and embolism reinforced; teach-back accurate. INR recheck and reassessment scheduled per the order. |
F3 Major bleeding (GI) — emergency | Anticoagulation-specific review during a visit found the patient reporting black, tarry stools and lightheadedness, with pallor and a blood pressure lower than baseline (hemodynamic detail in the Vital Signs and Cardiovascular modules). Findings are concerning for major gastrointestinal bleeding on anticoagulation. Emergency medical services were activated according to agency protocol; the patient was kept calm and positioned safely with nothing by mouth while awaiting EMS, and serial vital signs were documented. The provider was notified and family present were informed; the event, communications, and serial vital signs were documented pending transport, with follow-up to coordinate care on return home. |
F4 Fall with head strike on anticoagulation | Anticoagulation-specific review found that the patient had fallen and struck the head since the last visit; the patient is on a direct oral anticoagulant. No external major bleeding, but given the head strike on anticoagulation there is a risk of intracranial bleeding. The provider was notified at 09:30 with the fall, the head strike, and the anticoagulant; given the head injury on anticoagulation, urgent evaluation was directed and emergency medical services activated per policy. The patient was monitored for any change in level of consciousness, headache, vomiting, or focal symptoms pending transport, and family were informed; the event and communications were documented, with follow-up to coordinate care and review fall-prevention measures on return. |
F5 New interacting medication started | Anticoagulation-specific review found that the patient had been started on an antibiotic that interacts with warfarin since the last visit; no bleeding is reported and the most recent INR was in range. Findings indicate an increased bleeding or instability risk from the new interaction. Provider notified at 12:20 with the new medication and the interaction concern; order received to obtain an earlier INR and monitor for bleeding. Interaction avoidance, intensified bleeding precautions during the antibiotic course, and the earlier INR check reviewed with the patient; teach-back accurate. INR recheck and bleeding reassessment scheduled per the order. |
F6 DOAC nonadherence — missed doses | Anticoagulation-specific review found that the patient on a direct oral anticoagulant had missed multiple doses because of a routine disruption; no thromboembolic or bleeding symptoms are present. Findings indicate increased thrombosis risk from nonadherence with a short-half-life agent. Provider notified at 11:15 of the missed doses; instruction received on resuming the regimen and monitoring. Skilled teaching provided on the critical importance of consistent timing, the thrombosis risk of missed doses, an adherence aid, and the warning signs of stroke, embolism, and bleeding; the agency supported an adherence strategy. Teach-back accurate. Reassessment of adherence and symptoms planned at the next visit. |