The BBC News reported recently that a woman died after medical staff stored important clinical notes on sticky notepaper and paper towels. In August 2005, 78 year old Patricia Prowse was admitted to hospital for a minor operation. Eight days later Mrs Prowse suffered from a stroke and was not given essential anti-clotting medication.

The coroners verdict was logged as death by natural causes, but it was mentioned that errors had contributed to the womans death.

An inquest revealed that Mrs Prowse had been taking warfarin prior to going into hospital, and was supposed to have been given several injections of Clexane after the operation, but only received one jab, due to confusion and missing medical notes.

"On the evening of the procedure, the patient takes 1.5 times their "usual" warfarin dose for that day based on their regimen prior to holding warfarin for the procedure.  They then continue on their prior regimen thereafter, and an INR is checked in 1 week.

Use of this protocol requires a specific review for each patient to confirm that it is appropriate for that particular patient, and of course there are well-recognized patient groups that are NOT appropriately managed by this protocol. These groups include but are not necessarily limited to patients with recent thromboembolism, prosthetic cardiac valve in place less than 6 months, Bjork-Shiley valve, or the presence of three risk factors for thromboembolism [as defined by the AHA/ACC to include atrial fibrillation, LV dysfunction, previous thromboembolism, hypercoagulable condition, mechanical prosthesis], or the presence of a mechanical mitral prosthesis plus one risk factor."

This may be helpful guidance for some users who want to develop a protocol for post-procedure care. If you have any comments on the above or wish to provide any feedback or ideas, then please email us at syd@4s-dawn.com.