180 results for “anticoagulation”
43y · Female·Acute thrombosis of a prosthetic mitral valve
…cal breakdown in communication occurred between her IVF specialist and general practitioner regarding anticoagulation management after the IVF cycle. Each clinician assumed the other was managing warfarin dosing and rec…
81y · Male·Intracerebral haemorrhage in the setting of heparinisation for subclavian artery…
…Alan Webster with atrial fibrillation on long-term Warfarin underwent colonoscopy in August 2011. His anticoagulation was interrupted and bridging Clexane prescribed. Post-operatively, critically sub-optimal communicati…
68y · Male·Pulmonary thromboembolus secondary to deep vein thrombosis
…or pulmonary emboli, was treated for rectal cancer requiring chemotherapy and major surgery. Warfarin anticoagulation was appropriately ceased due to bleeding risk from the cancer and instability during chemotherapy. Af…
73y · Male·Haemorrhagic stroke in the setting of recent inguinal hernia surgery and change …
…ic transformation following thrombolysis, resulting in death. Key failures included: failure to chart anticoagulation post-operatively (prescribing omission error), inadequate post-operative review documentation, lack o…
Female·retroperitoneal blood loss in a setting of anticoagulation therapy following hip…
Valerie Kolts died from retroperitoneal blood loss following hip replacement surgery while on anticoagulation therapy. The coroner found no lack of care contributed to her death. Although some clinical signs wer…
76y · Male·pulmonary thromboembolism in the setting of deep vein thrombosis
…oxaparin was prescribed as VTE prophylaxis during admission. At discharge, the decision to recommence anticoagulation was deferred to the GP rather than being managed by the specialist team. Critically, VTE prophylaxis …
90y · Female·Right acute on chronic subdural haematoma sustained in a fall in the setting of …
…in (a second anticoagulant) despite warfarin being documented in multiple clinical records. This dual anticoagulation caused the small bleed to expand catastrophically, resulting in death. The coroner found the death pr…
68y · Male·Dilated cardiomyopathy with previous aortic valve replacement and aortic graft
…rhage as a contributing factor. He developed a large perinephric haematoma (1900mL) secondary to over-anticoagulation (INR 3.5, prothrombin 49 seconds) from warfarin. His GP did not receive anticoagulation monitoring re…
45y · Male·massive pulmonary embolism due to deep vein thrombosis of the left leg
…mmobilization. He was discharged with the fracture in a plaster cast but did not receive prophylactic anticoagulation therapy. The coroner found he was at high risk for DVT (lower limb fracture, infection, prolonged imm…
48y · Female·intracerebral haemorrhage on a background of anticoagulation therapy for a recen…
…on. The treating team appropriately invoked involuntary mental health powers to administer injectable anticoagulation (enoxaparin) and antipsychotic therapy (paliperidone). This avoided both stroke recurrence and psychi…
81y · Male·Retropubic and retroperitoneal haemorrhage complicating pelvic fractures with co…
… INR testing on emergency admission despite warfarin use—a routine test that would have revealed over-anticoagulation; (2) failure to recognize bleeding risk from minimally displaced pelvic fractures combined with exces…
64y · Male·hypoxic-ischaemic encephalopathy complicating cardiac arrest due to retroperiton…
…no blood tests performed after admission to monitor haemoglobin or renal function despite therapeutic anticoagulation; (2) nursing staff ignored patient and family requests for medical review when signs of shock (pallor…
95y · Female·acute left subdural haematoma complicating anticoagulant therapy for deep vein t…
… suspected pneumonia and cellulitis. She developed deep vein thrombosis and was started on enoxaparin anticoagulation. She became confused and agitated, prompting a Mental Health Act order for delirium management. She s…
56y · Female·Intracranial haemorrhage whilst undergoing intravenous heparin therapy
…ce of focal neurological signs, which was not a reasonable diagnosis. She was admitted and started on anticoagulation (Clexane then heparin). When she deteriorated neurologically at 10:30pm with new visual field loss, h…
74y · Female·Cardiac arrest due to pulmonary embolism secondary to deep venous thrombosis
…and access block. A D-Dimer test showed elevation; DVT ultrasound was scheduled for the next morning. Anticoagulation was not administered due to concern about recent gastric ulcer bleeding and recurrent H. pylori. That…
34y · Male·Acute intracranial haemorrhage, malignant hypertension, renal artery stenosis
…eral renal artery stenosis and two undiagnosed brain lesions, then returned to prison on 16 June. His anticoagulation management was complex; warfarin dosing was adjusted multiple times with subtherapeutic INR levels. O…
57y · Male·large volume ischaemic infarct (stroke)
…tion was only identified retrospectively by specialist neuroradiologists. Mr French was discharged on anticoagulation but re-presented with worsening symptoms on 7 August. A critical decision to reverse his warfarin was…
81y · Female·hypovolaemic shock following bleeding from the site of a femoral angiogram
… for ischaemic leg and underwent unsuccessful thrombolytic therapy. Subsequently commenced on Heparin anticoagulation but therapeutic range took 38 hours to achieve, exposing her to over-anticoagulation. Critical failur…
53y · Female·infarction of the transverse colon due to mesenteric/retroperitoneal haemorrhage…
…infarction secondary to mesenteric/retroperitoneal haemorrhage and incisional abdominal hernia during anticoagulation therapy. She was admitted to hospital with delirium; an organic cause (UTI) was found and treated. A …
59y · Male·pulmonary thromboemboli due to deep vein thrombosis following right hip replacem…
…opaedic review suggested his polycythaemia and BMI warranted high-risk classification with additional anticoagulation (e.g. warfarin). Additionally, his enoxaparin dose was reduced from 100mg to 70mg twice-daily on day …
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