Communication breakdowns in healthcare settings can have severe – even deadly – consequences, and a recent case serves as a prime example.
A Chicago jury awarded a record verdict to a 72-year-old man who suffered a devastating stroke due to medical malpractice.
How Failures in Communication Impact Medical Care
At the heart of the Pierce malpractice case was the failure of doctors to communicate with the patient and other providers about the ongoing care and monitoring needed to properly manage the anticoagulant Coumadin (generic name Warfarin).
Research shows that poor communication between health providers is one of the leading causes of medical errors and patient harm. As long ago as 2008, the Joint Commission reports showed that communication failures were implicated at the root of over 70 percent of sentinel events. According to the Joint Commission, a sentinel event is an event that results in death, permanent harm, or severe temporary harm.
What Happened to Mr. Pierce
In the case referenced above, Christopher T. Hurley, Mark R. McKenna, and Clint T. Pierce of the law firm Hurley McKenna & Mertz, P.C. won a record setting jury verdict of over $41 Million against OSF HealthCare System on behalf of a 72-year-old man who suffered a catastrophic stroke because the defendants failed to properly manage his blood thinning medication Coumadin.
The 72-year-old man, Craig Pierce, was hospitalized for pneumonia in 2016 and later developed a kidney injury as well as being diagnosed with atrial fibrillation (AFib). Mr. Pierce was discharged with orders for dialysis to treat the kidney injury and with prescribed anticoagulants used to prevent blood clots, which are a risk to patients with AFib.
As stated previously, anticoagulants must be carefully managed through medical professional blood testing to be sure the blood’s ability to clot is at the right levels. Without that testing, the blood can clot too easily, leading to stroke, or it cannot clot easily enough, leading to the risk of bleeding.
Expert Guidance on Warfarin
The American Heart Association says in its Patient’s Guide to Taking Warfarin that the effect of warfarin must be monitored carefully with blood testing. Based on the results of the blood test, your daily dose of warfarin will be adjusted to keep your clotting time within a target range.
In the case of Mr. Pierce, he suffered a catastrophic stroke that led to multiple life-altering outcomes.
Mr. Pierce was released from the hospital with no instructions or orders to receive the needed testing, nor was he advised to be tested by the doctor who oversaw his dialysis. This failure to communicate demonstrated a breakdown in the chain of care that led to a devastating outcome.
On May 7, 2024, the jury rendered a verdict in favor of both Craig and Susan Pierce and against defendant OSF HealthCare System andoth medical providers. The jury awarded both Plaintiffs the sum of $41,149,942.38 in damages, allocating $35,149,942.38 of the award to Craig Pierce for his injuries, and $6,000,000.00 to Susan Pierce for her injuries including the loss of her relationship with her husband and the loss of her husband’s services.
Communications Strategies to Prevent Tragedy
To prevent situations like those that significantly impacted Mr. Pierce’s quality of life, healthcare organizations must implement robust communication strategies. Patients should receive care that is based on the following:
- Standardized handoff procedures to ensure critical information about anticoagulant therapy and other drug therapies are communicated during care transitions.
- Comprehensive patient education programs that clearly explain the risks and benefits of anticoagulant and other therapy, proper dosing, potential side effects, and when to seek medical attention.
- Implementation of medication reconciliation processes to prevent duplicate therapies or dangerous drug interactions.
- Utilization of health information technology to improve communication between healthcare providers and ensure timely follow-up on lab results.
- Encouraging patients to be active participants in their care by asking questions and reporting any concerns promptly.
- Regular training for healthcare providers on effective communication techniques and the specific challenges associated with anticoagulant therapy.
Did the failure of a health system or provider to properly communicate result in death or damage to your or someone you love? This may indicate that there was medical malpractice.
Questions regarding this case or malpractice can be directed to Mark McKenna at (312) 602-1417 (mmckenna@hurley-law.com), or Clint Pierce at (312) 283-4597 (cpierce@hurley-law.com).
