Patient death

Although it is certainly very possible that the leg swelling was due to clots, it is not the only explanation. Pt could have had afib or could have developed dvt and thrown the clot very quickly.

With BLE chronic edema and bilateral changes i would not have gone straight to DVT at all either- much more likely cellulitis, reaction to med, vascular insufficiency etc.

As for not restarting the anticoagulant I'm just guessing but I've seen many many older sick fall risk pts taken off anticoagulants due to very high fall risk. There is a formula that gives probability of clots given pt condition. If the pt is at a higher risk of falls (and subsequent head bleeds) it makes sense to dc it.

Which brings me to my final point. Even if the med issue was an error or oversight it may not have made a difference. You didn't give an age but did say this was a person with "multiple comorbidities" causing "generalized weakness" severe enough to need rehab. That is a pretty sick pt who is at risk of death from any number of things. The PE could possibly even have occurred if she was anticoagulated. Or she could have died from something else. This was a high risk pt for numerous problems. Combine that with an atypical presentation and sometimes these things can't be prevented even if in hindsight it all makes sense.

Working in a SNF you will see a lot of pts who are getting treated for many problems that all are potentially or eventually lethal. You can't save everyone from everything. Multiple people looked at the meds and multiple people assessed the leg issues. It's no different than if she had died of a ruptured appendix with no prior complaint of and pain or gi sx-an atypical presentation often leads to diagnostic delay and sometimes bad outcomes. No matter how experienced you are you can only see what is in front of you.

Although it is certainly very possible that the leg swelling was due to clots, it is not the only explanation. Pt could have had afib or could have developed dvt and thrown the clot very quickly.

With BLE chronic edema and bilateral changes i would not have gone straight to DVT at all either- much more likely cellulitis, reaction to med, vascular insufficiency etc.

As for not restarting the anticoagulant I'm just guessing but I've seen many many older sick fall risk pts taken off anticoagulants due to very high fall risk. There is a formula that gives probability of clots given pt condition. If the pt is at a higher risk of falls (and subsequent head bleeds) it makes sense to dc it.

Which brings me to my final point. Even if the med issue was an error or oversight it may not have made a difference. You didn't give an age but did say this was a person with "multiple comorbidities" causing "generalized weakness" severe enough to need rehab. That is a pretty sick pt who is at risk of death from any number of things. The PE could possibly even have occurred if she was anticoagulated. Or she could have died from something else. This was a high risk pt for numerous problems. Combine that with an atypical presentation and sometimes these things can't be prevented even if in hindsight it all makes sense.

Working in a SNF you will see a lot of pts who are getting treated for many problems that all are potentially or eventually lethal. You can't save everyone from everything. Multiple people looked at the meds and multiple people assessed the leg issues. It's no different than if she had died of a ruptured appendix with no prior complaint of and pain or gi sx-an atypical presentation often leads to diagnostic delay and sometimes bad outcomes. No matter how experienced you are you can only see what is in front of you.

This really made me feel a lot better about the situation. I do not quite remember, but I believe she was previously on the anticoagulant due to a hx of chronic afib. The swelling to her legs I do not think was from a clot. Rather I think the edema masked the clinical presentation for the DVT, but in hindsight that must be what was occurring with the discoloration and pain to the one extremity. The patient had a LOT of other issues going on.

The acuity in the SNF setting is sometimes astounding to me. I have had shifts where I had 20+ patients with numerous ISO/c diff, multiple IV abt, IV fluids, fluid restrictions, daily labs being monitored, and 5-6 wound care treatments on my shift alone. Not to mention all the Coumadin orders I have to chase down, sometimes 3-4 a day from multiple different physicians, the med pass, the family members, the dementia patients, and oh the charting. But I really do love my job. It gets less overwhelming every day.