Hematologist here. Sad and unfortunate situation of miscommunication. As most of my patients who are treated with warfarin are elderly or comorbid with multiple medications I generally prescribe only one strength tablet (ie 5 mg tabs) and instruct the patient to take “by the tab”. For example 1 tab daily on weekdays and half tabs on weekends. I find prescribing in mgs for a drug that requires frequent adjustments to be too confusing for patients. Make sure your pharmacy and hospital are on board with this.
Totally agree. Thankfully with escripts it's much easier to determine whether or not they meant tabs or mg. At that point it really does become negligence on the pharmacist for not clarifying units.
But as you know a common scenario with mg prescriptions for warfarin is patients receiving different strength tabs and having to do the math themselves or start counting tabs that look the same. In the US the coloring scheme for different strengths is unique but does not hold true for other places.
In this case 4.5 mg tabs can be:
x4 1mg tabs + x0.5 1mg tab or
x2 2mg tabs + x0.5 1mg tab or
X1 2.5 mg tabs + x1 2 mg tabs
Too much room for error IMO. Keeping it simple with a single strength and per tablet instructions works well for my patient population.
I wondered that myself. My guess would be that they were trying to get closer to the middle of the 2-3 range. If they would have left him at the 3mg dose, the accidental overdose would have been less severe, but might not have made a difference in the outcome? Hard to know.
Oh, you know, I misread it. I thought they DECREASED the dose when they hit 2.1. Never mind :)
I agree, no way to tell if it would change the outcome. If you assume it would, maybe it's a good argument for using a dosing nomogram instead of going by your gut to dose Coumadin.
Tough case to read as a pharmacist. I'm surprised they didn't go after the pharmacist who took down the order. Even a state regulatory board would likely go after them for something like failure to counsel. But I have to wonder if patient counseling would have even prevented this. We don't sit down with patients so "hey heads up your physician changed your warfarin dosing" would probably be the extent of it. Maybe in that scenario it makes sense to go after the corporate-owned pharmacy.
Do most retail pharmacists carry their own malpractice insurance? I'm guessing they didn't go after her because she didnt have her own insurance, the big money was in going after the pharmacy chain.
Most don't even though coverage is pretty cheap. When I worked for the chains I was the only one at my store of 4 pharmacists that had a policy. If the chains purchase a policy for their employed pharmacists I'm just not aware of it.
Hematologist here. Sad and unfortunate situation of miscommunication. As most of my patients who are treated with warfarin are elderly or comorbid with multiple medications I generally prescribe only one strength tablet (ie 5 mg tabs) and instruct the patient to take “by the tab”. For example 1 tab daily on weekdays and half tabs on weekends. I find prescribing in mgs for a drug that requires frequent adjustments to be too confusing for patients. Make sure your pharmacy and hospital are on board with this.
Smart, potentially may have saved this patient.
Totally agree. Thankfully with escripts it's much easier to determine whether or not they meant tabs or mg. At that point it really does become negligence on the pharmacist for not clarifying units.
Agree much easier with escripts.
But as you know a common scenario with mg prescriptions for warfarin is patients receiving different strength tabs and having to do the math themselves or start counting tabs that look the same. In the US the coloring scheme for different strengths is unique but does not hold true for other places.
In this case 4.5 mg tabs can be:
x4 1mg tabs + x0.5 1mg tab or
x2 2mg tabs + x0.5 1mg tab or
X1 2.5 mg tabs + x1 2 mg tabs
Too much room for error IMO. Keeping it simple with a single strength and per tablet instructions works well for my patient population.
Good idea.
Why was the Coumadin dose decreased when the INR was 2.1? I know INR targets for a.fib to be 2-3 (non-valvular) or 2.5-3.5 (valvular).
I wondered that myself. My guess would be that they were trying to get closer to the middle of the 2-3 range. If they would have left him at the 3mg dose, the accidental overdose would have been less severe, but might not have made a difference in the outcome? Hard to know.
Oh, you know, I misread it. I thought they DECREASED the dose when they hit 2.1. Never mind :)
I agree, no way to tell if it would change the outcome. If you assume it would, maybe it's a good argument for using a dosing nomogram instead of going by your gut to dose Coumadin.
Ha, I actually misread your comment as "increased", which I think is still an interesting discussion.
Tough case to read as a pharmacist. I'm surprised they didn't go after the pharmacist who took down the order. Even a state regulatory board would likely go after them for something like failure to counsel. But I have to wonder if patient counseling would have even prevented this. We don't sit down with patients so "hey heads up your physician changed your warfarin dosing" would probably be the extent of it. Maybe in that scenario it makes sense to go after the corporate-owned pharmacy.
Do most retail pharmacists carry their own malpractice insurance? I'm guessing they didn't go after her because she didnt have her own insurance, the big money was in going after the pharmacy chain.
Most don't even though coverage is pretty cheap. When I worked for the chains I was the only one at my store of 4 pharmacists that had a policy. If the chains purchase a policy for their employed pharmacists I'm just not aware of it.