practice of Medicine


Orthopedic Surgery Toolkit

August 1, 2019

Lessons learned

Weak on-call handoff and discharge instructions botch patient’s Coumadin therapy

A 46- year-old obese Caucasian female, underwent aortic heart valve surgery for aortic insufficiency with left sided ventricular enlargement on June 6, 2005.

During the post-operative hospital stay, the attending cardiologist periodically adjusted the patient’s Coumadin dose over three days. The cardiologist increased the dose each day, beginning with 5 mg/day, then 7.5 mg/day and …

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The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.