What is the term for a situation where a patient fails to stop taking warfarin (coumarin) as instructed, the medical team becomes aware of this, and the surgery is postponed to prevent potential complications?

Near Miss: When Warfarin Continuation Results in Surgery Postponement

The situation described is a "near miss" (option A), where a potential adverse event was identified and prevented before harm occurred to the patient.

Definition and Classification

A near miss occurs when a patient safety incident is caught before reaching the patient or before causing harm. In this case:

1. The patient failed to stop warfarin despite clear instructions
2. The surgical team identified the continued anticoagulation before surgery
3. The surgery was postponed to prevent potential serious bleeding complications

This represents a classic near miss scenario where the system's safety checks functioned properly by detecting the continued anticoagulation before proceeding with surgery 1.

Why This Is Not an Adverse Event

An adverse event would have occurred if:

• Surgery had proceeded despite the patient being anticoagulated
• The patient experienced significant bleeding complications during or after surgery

Since the surgery was postponed before any harm occurred, this remains a near miss rather than an adverse event 1.

Why This Is Not Medical Negligence

Medical negligence requires:

• A breach of the standard of care
• Resulting harm to the patient

In this case:

• The healthcare team followed proper protocol by checking anticoagulation status before surgery
• The surgery was appropriately postponed when the risk was identified
• No harm came to the patient

The medical team acted appropriately by postponing surgery when they discovered the patient remained anticoagulated 1.

Perioperative Management of Warfarin

According to the American College of Chest Physicians guidelines:

• Warfarin should typically be stopped 5-6 days before elective surgery to allow INR normalization 1
• For patients at high risk of thromboembolism, bridging anticoagulation may be considered 1
• INR testing should be performed before surgery to confirm adequate reversal of anticoagulation 1

Importance of Proper Perioperative Anticoagulation Management

Failure to properly manage perioperative anticoagulation can lead to:

1. If warfarin is continued:

   • Increased risk of significant perioperative bleeding
   • Need for blood transfusions
   • Potential for surgical complications

2. If warfarin is stopped without proper bridging in high-risk patients:

   • Increased risk of thromboembolism
   • Potential for stroke or other embolic events 2

Key Points for Prevention of Similar Near Misses

1. Clear communication:

   • Written and verbal instructions about medication management
   • Multiple reminders about stopping anticoagulation
   • Verification of understanding through teach-back methods

2. Preoperative verification:

   • Mandatory medication reconciliation before surgery
   • INR testing on or before the day of surgery
   • Clear protocols for managing patients who remain anticoagulated

3. System safeguards:

   • Automated reminders for patients on anticoagulation
   • Standardized preoperative checklists including anticoagulation status
   • Clear decision algorithms for proceeding or postponing surgery

This near miss highlights the importance of proper safety checks in the perioperative period, which successfully prevented what could have been a serious adverse event had the surgery proceeded with the patient fully anticoagulated.