Texting resident fails to stop warfarin; hemopericardium ensues - PulmCCM
Apr 202012

Texting while doctoring is a newly hyped threat to patient safety. Multitasking and the constant flow of new distracting information in the form of alarms, interruptions, pages, etc. have always been inherent to the practice of medicine. But some are wondering if the ubiquitous temptations of personal social media-enabled smartphones and tablets in the medical workplace are a recipe for disaster. The New York Times recently did a trend piece on distracted doctors checking Facebook and text messaging in the ICU and even in the operating room, and hospitals formulating new policies on personal technologies to head off the bad outcomes and lawsuits they worry might be in our future.

Here's an anecdotal case from the Agency for Healthcare Research and Quality (AHRQ)'s website about a resident who got distracted by a text message instead of putting in an order to stop warfarin after being instructed to during rounds. No one checked the INR afterward, since they assumed warfarin was discontinued. No one checked the medication list for the next few days either, "because of the robust CPOE system." Unfortunately, the first recognized sign of the patient's warfarin overdose was his cardiac tamponade from hemopericardium days later.

The case was submitted anonymously, and there is no indication that AHRQ verified it. Urban legend or cautionary tale? You be the judge.

Like any new technology, smartphones hold potential for benefit or harm, and the important thing is personal responsibility and finishing what you start ... Woops, I just got a text. Hang on a sec, I'll be right ba

Order Interrupted by Text: Multitasking Mishap, AHRQ website 

Distracted doctoring piece, New York Times

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  3 Responses to “Texting resident fails to stop warfarin; hemopericardium ensues”

  1. Blaming smartphone for this mishap is absolutely wrong.
    Fault lies with “NOT REVIEWING” the medication list daily. The intern, resident and eventually the attending is to be blamed for not doing that.

  2. This is probably nonsense. Most warfarin is dosed by pharmacy and INRs and Hemograms are part of the protocols when patients are on these meds. If the patient was on warfarin, an INR would have been drawn as part of the pharmacy protocol, so I say this is an urban legend story.

  3. Unfortunately, I can see this happening. At our facility pharmacy does not routinely dose warfarin, and MDs are too overloaded to check every lab every time, especially when they are new. That’s no excuse–nurses shouldn’t administer warfarin without an INR level, but again, no one is perfect. That’s precisely why there should be an actual robust CPOE. I could tell you story after story of near misses based on situations like this. Anyone who says this could never happen is confusing could with should, I think.