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A 76-year-old man with an eighth-grade education who is chronically anticoagulated on warfarin for a history of paroxysmal atrial fibrillation, is admitted to the hospital with an upper GI bleed. His warfarin is reversed with vitamin K, and upper endoscopy reveals an actively bleeding duodenal ulcer. A CLO test confirms the ulcer was caused by H. pylori, and the patient is then placed on a proton pump inhibitor and appropriate antibiotics. After discussion with the GI consultants, the hospitalists advise the patient as he is being discharged to follow up with his primary care physician (PCP) and that he can restart his warfarin in 6 weeks.

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When the patient arrives for his outpatient follow-up visit, his PCP is surprised to hear that her patient was in the hospital. No discharge summary is available, so his doctor relies on the patient to tell her what happened. Unfortunately the patient does not remember all the details. He does remember something about the problem being caused by an “infection in my stomach,” and he also notes that he was taken off his warfarin. Worried that her patient might have a stroke if he remains off his anticoagulant and thinking her patient had a viral gastritis, the PCP restarts his warfarin. One week later, the patient develops melena and is readmitted to the hospital with a recurrent GI bleed.

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1. What barriers might have prevented the patient from accurately remembering the details of his hospital stay?

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2. What practices could prevent this type of medical error?

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Answers

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  1. In the above scenario, there are several potential barriers. First and foremost, the patient was told vital information about his warfarin at the time of his discharge—a time during which his mind may have been on many other things: how he was going to arrange for transportation home, how he was going to pay for his new prescriptions, when the nurse would be along to take out his IV, etc. His advanced age and the fact that he was recovering from a significant acute illness also play a role in his ability to remember information—elderly patients can be significantly cognitively impaired when ill and this impairment can be very hard to detect in the normal course of a conversation. Finally, this patient's educational status should alert us to the fact that he might have basic or below-basic health literacy status. Patients with low health literacy find it particularly difficult to understand and retain information given to them in a 1-time, verbal format.

  2. One way doctors can be sure they have communicated effectively to patients is through the process of “teach-back.” Teach-back involves discussing an issue with a patient, and then asking the patient to share with you what was understood about the concept being discussed. The process is then repeated until the patient demonstrates full understanding of the ...

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