What should be done after a patient with hyperlipidemia, currently on atorvastatin (generic name), is mistakenly given warfarin (anticoagulant) instead of their scheduled atorvastatin (HMG-CoA reductase inhibitor)?

Immediate Disclosure to Patient is Mandatory

You must inform the patient directly of the medication error and its potential complications immediately (Option D). This is the ethically and legally required course of action when a medication error occurs, regardless of whether harm has resulted 1, 2.

Ethical and Legal Obligations

• Direct patient disclosure is a fundamental ethical duty that takes precedence over administrative channels or family notification 1, 2
• The patient has an absolute right to know what medications they have received and any potential risks, even when no immediate harm has occurred 1, 2
• Transparency in medical errors is now considered the standard of care across all medical specialties and is supported by patient safety organizations 1, 2

Why Other Options Are Inappropriate

• Option A is unacceptable: The absence of immediate harm does not eliminate the duty to disclose; warfarin carries significant bleeding risk and the patient needs to be monitored for complications 1, 2
• Option B undermines patient autonomy: While management should be notified separately, delegating disclosure to administrators delays critical information and violates the physician-patient relationship 1, 2
• Option C violates patient confidentiality: Informing the spouse before the patient (who is alert and oriented) bypasses the patient's right to receive their own medical information first 1, 2

Specific Information to Communicate

• Explain what happened: A single 5 mg dose of warfarin was mistakenly administered instead of atorvastatin 1, 2
• Describe potential complications: Warfarin is an anticoagulant that increases bleeding risk, though a single dose carries relatively low risk in a patient without other risk factors 1, 2
• Outline monitoring plan: The patient should be monitored for signs of bleeding (bruising, blood in urine/stool, prolonged bleeding from cuts) and may need INR testing if symptoms develop 1, 2
• Express appropriate regret: Acknowledge the error and the steps being taken to prevent recurrence 1, 2

Clinical Context for This Specific Case

• A single 5 mg dose of warfarin in a young, healthy 20-year-old without other bleeding risk factors is unlikely to cause significant harm, but monitoring remains essential 1, 2
• The patient's rhabdomyolysis and atorvastatin therapy are separate issues; there is a documented interaction risk between warfarin and statins that can increase INR, though this typically requires ongoing combination therapy 3, 4, 5
• No reversal agents (vitamin K or PCC) are indicated for a single erroneous dose without elevated INR or bleeding 1, 2

Follow-Up Actions

• Document the error thoroughly in the medical record, including the disclosure conversation 1, 2
• Report through institutional error reporting systems to prevent future occurrences 1, 2
• Consider checking an INR in 24-48 hours if clinically indicated, though this is not mandatory for a single dose 1, 2
• Resume atorvastatin as scheduled and ensure proper medication reconciliation processes 6