A new report by the healthcare safety watchdog, HSSIB, has highlighted the risks to patients’ safety from hospital mistakes in managing their blood-thinning anticoagulant medication before and after surgery or other invasive procedures. The investigation report, Medication not given: anticoagulation before and after a procedure, explores failures in the hospital care provided to an elderly patient who suffered a stroke and died after his regular apixaban anticoagulant medication was paused for ten days for a delayed pleural aspiration procedure. Whilst HSSIB’s report focusses on one patient’s care and the factors which led to the mismanagement of his medication and his death, its lessons also apply to many other life-changing injuries caused by anticoagulation errors, such as venous thromboembolism (VTE) (pulmonary embolism, DVT), cerebral venous thrombosis (CVT) or stroke, heart attack, limb ischaemia and amputation. The patient’s experience HSSIB investigated the hospital care of an elderly man who was suffering from breathlessness, heaviness in his chest and nosebleeds. He was examined in the emergency department and was noted to have pre-existing cardiovascular conditions including high blood pressure, heart failure and atrial fibrillation (AF). His medical history was later updated to note that he had suffered rheumatic fever as a child. These conditions, and his past history of stroke a few years earlier, increased his risk of stroke from blood clots (thrombosis). He took regular medication including an anticoagulant called apixaban, to prevent blood clots and reduce his risk of having an ischaemic stroke. In the emergency department, he was given IV antibiotics for a suspected chest infection. A chest X-ray revealed that he had pleural effusions (a build-up of excess fluid in the space between the tissue layers that cover the lungs and the chest wall). He was admitted to the hospital and that afternoon he suffered a severe nose-bleed, which was treated by packing his nose. He was then moved to the acute medical unit, where he was seen by a consultant that evening. His blood tests showed blood-clotting abnormalities, and a chest examination confirmed a diagnosis of pleural effusion and pneumonia. The plan for his care included continuing his antibiotics but pausing his apixaban owing to his nosebleeds. A CT scan of his chest was requested. It was noted that he was to be transferred to the ‘respiratory ward only’ as he needed a pleural aspiration procedure to remove the excess fluid. Over the next few days he was cared for on medical wards whilst waiting for the CT scan and for transfer to the respiratory ward for his pleural aspiration procedure. His nose was unpacked two days later and he had no more nosebleeds. His CT scan, which finally took place on his 7th day in hospital, revealed an enlarged heart, a collapsed left lower lung lobe and pleural effusions on both sides. By the 10th day his doctors noted that he had a ‘worsening effusion’ and another referral was made to the respiratory team. As no beds were available on the respiratory ward, arrangements were made for him to have the pleural aspiration in the procedure room on the respiratory ward but then to return to the medical ward. After the procedure, the respiratory specialist doctor’s instructions to the medical ward team for his ongoing care did not mention restarting his anticoagulant medication. The next day, after the medical ward round, a doctor noted an intention to prescribe on the electronic prescribing (ePMA) system that the patient’s apixaban should be restarted that evening, but it didn’t happen. The following day, a nurse noticed that the patient had a left-sided facial droop, slurred speech and weakness in one hand. After further investigations, including an urgent CT head scan, he was diagnosed with stroke. He died two days later. HSSIB identify multiple contributory factors leading to anticoagulation error HSSIB’s investigation found that multiple factors contributed to the decision-making and anticoagulation errors in the patient’s hospital care. The emergency department (ED) doctor’s decision to pause the patient’s apixaban was appropriate given the bleeding risk from his severe nosebleeds. A pause in his anticoagulant medication would also have been required in the days immediately before the pleural aspiration, to reduce the risk of excessive bleeding after the invasive procedure. However, HSSIB questioned why the patient’s anticoagulation needs had not been reviewed when the delayed procedure did not take place in the expected timeframe. The investigation found that risk assessment and decision-making were made more difficult by inaccessible past clinical information about the patient, variations in hospital care processes and consequent uncertainty about when the delayed procedure would take place. Staff shortages, including cuts in the former specialist nursing and administrative support roles which were critical for coordination and follow-up during a patient’s care, meant that respiratory referrals weren’t followed up in a timely way. When the patient’s procedure was delayed, there was no reassessment of the decision to pause his apixaban and no prompt to review the paused anticoagulant medication from the ePMA prescribing system. Similarly, after the procedure, nothing in the respiratory ward’s post-procedure documentation prompted staff to review whether he should restart his anticoagulant medication. Bed shortages and a ‘mismatch between demand and capacity’ within the NHS trust’s respiratory service prevented the patient from being cared for on the respiratory ward or receiving specialist respiratory input whilst on the medical ward, despite the mandate in his records for respiratory ward care. In addition, relevant local guidance was difficult for staff to access on the NHS trust’s computer systems, and where it was available it didn’t reflect the latest national guidelines. Medical negligence claims for injury caused by anticoagulation errors As healthcare becomes more complex, with an ageing population and increasing numbers of people with multiple comorbidities dependent on consistent, joined up and efficient NHS care, HSSIB’s investigations provide valuable insight into how and why common patient safety incidents continue to occur. At system-wide level, understanding should lead to learning, and from learning to improvement. Meanwhile those who are severely injured by negligent errors are entitled to be fully compensated for their disability, loss and lifelong needs arising from their injury, which may include adapted housing, therapies and care. Anticoagulation errors often feature in medical negligence claims involving limb ischaemia and amputation, thrombosis and venous thromboembolism (VTE) and its many consequences, such as stroke or heart attack, and maternal death. If you or a family member have suffered severe injury as a result of medical negligence or have been contacted by HSSIB/MNSI or NHS Resolution, you can talk to a solicitor, free and confidentially, for advice about how to respond or make a claim by contacting us.
