An elderly man was on warfarin for atrial fibrillation and had not had an INR test for sometime. He unfortunately developed gastro-intestinal bleeding and became very unwell. When he arrived at hospital his INR was 8.1. In spite of multiple blood transfusions he died the next day.
This tragic story reinforces the importance of two areas we have covered in Coagulation Conversation posts
1. The dangers of gastro-intestinal bleeding
2. The importance of regular INR testing
the ideal interval between tests was discussed in the first scene of our saga
The coroner’s report
The pharmacy which dispensed the man’s warfarin informed us of the coroner’s report of the case. This pharmacy offers our CPAMS warfarin management service but the man had not been referred to this service.
The coroner found a leaflet about CPAMS with the deceased man’s medications and did some research about this service. CPAMS offers a comprehensive warfarin management service supervised by trained pharmacists and achieves very good warfarin control. INR Online provides the CPAMS software which has many ways of making sure people get regular INR tests.
- the software suggests monthly tests unless the pharmacist changes the default setting
- patients have a printed calendar to take away showing them what dose of warfarin to take each day and when to attend for the next test
- patients receive an email reminder when their test is due
- the software provides pharmacists with electronic flagging of patients who have not attended for testings, with patients’ contact details directly to hand
The coroner recommended that:
“Where a Community Pharmacy Anticoagulation Management Services (CPAMS) pharmacy is readily available a patient should in my view be directed, as far as is possible, to have their warfarin dispensed from that CPAMS pharmacy, and in accordance with the CPAMS testing regime.”
The coroner also suggested that when CPAMS is not available, there should be
- methods to check if patients are having regular INR tests,
- a protocol of appropriate testing intervals
- ability to communicate with carers or other family members if the patient has limitations due to health and/or age
- mandatory INR testing before the dispensing of repeat warfarin prescriptions
- good communication between pharmacies and medical practices
Our condolences to the family of the man who died.
While we cannot be sure if not using the CPAMS service had any bearing on this case, we obviously think the CPAMS service is a good way to manage warfarin. Several peer-reviewed articles in medical journals have shown this to be the case.
Paul has already written to the Ministry of Health asking them to expand the CPAMS service as it is popular with patients and pharmacists, decreases GP workloads and saves lives. We can only hope that this recommendation from a coroner will encourage the Ministry to consider expansion of the service with more urgency.