Discharge medication conflict: warfarin, aspirin, and a fall
You are a practice nurse in a GP surgery. You are reading a hospital discharge summary for Mrs Eileen Park, 74, who was admitted after a fall at home with a laceration to her forehead. There was no fracture and no intracranial bleed on CT. She has atrial fibrillation, hypertension and osteoarthritis. The discharge summary states: “Warfarin stopped due to INR 5.8 on admission. Start aspirin 75 mg daily. GP to repeat INR in 5 days and consider restarting anticoagulation.” The ward medication chart lists: “Warfarin 4 mg daily - stop; aspirin 75 mg daily - start; paracetamol 1 g QDS - continue.” A GP referral letter from three months ago states: “Continue warfarin; target INR 2.0–3.0. Avoid aspirin unless there is a cardiac indication.” Mrs Park tells you she has never taken aspirin and asks, “Does this mean my warfarin is finished for good?”
1. Identify two discrepancies in the documents and explain their clinical significance.
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Discrepancy 1: warfarin versus aspirin The discharge summary says to stop warfarin and start aspirin, while the recent GP letter says continue warfarin with a target INR of 2.0–3.0 and avoid aspirin unless there is a cardiac indication. This matters because Mrs Park has atrial fibrillation: warfarin is being used for stroke prevention, and aspirin alone is generally less effective for this indication. The fall and INR 5.8 explain why warfarin was interrupted, but they do not automatically mean aspirin is the correct long-term replacement.
Discrepancy 2: ‘consider restarting’ versus a definite stop The summary both stops warfarin and says the GP should ‘consider restarting anticoagulation’ in 5 days. That is not a clear plan. It leaves the patient without a defined anticoagulation strategy and creates a window where she may start aspirin without a documented cardiac reason.
Clinical significance: the risk is not just a paperwork error. She could be left under-protected against stroke, or exposed to bleeding from dual therapy if aspirin is added without clarification. The INR of 5.8 and recent fall also mean her bleeding risk needs active review.
2. What would you do before Mrs Park leaves the surgery?
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Actions before she leaves
- Do not tell her to start aspirin yet. Confirm whether the hospital intended aspirin as a temporary measure, a replacement, or an addition. Check whether there is a cardiac indication such as recent ACS or stent.
- Contact the discharging team or the GP who wrote the letter and ask for a written, unambiguous plan: stop warfarin permanently, bridge with another agent, or restart warfarin when INR is safe.
- Check for bleeding: bruising, gum bleeding, black stools, haematuria, headache, and any new neurological symptoms after the fall.
- Arrange the INR and a medication review within the stated timeframe, and document the discrepancy and who was contacted.
Reasoning: the nurse’s role is to reconcile and escalate, not to independently choose an anticoagulant. Starting aspirin without clarification could cause harm, and simply stopping warfarin could increase stroke risk.
3. How would you answer her question: “Does this mean my warfarin is finished for good?”
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Suggested response
“Not necessarily. The hospital stopped your warfarin because your blood was too thin at the time and you had a fall. The discharge letter also suggests your GP may restart it after checking your blood again. There is a difference between the hospital’s advice and your previous plan, so I am going to confirm which medicine is right for you before you change anything. Please do not start the aspirin until we have checked. If you notice any bleeding, a bad headache, or black stools, contact us straight away.”
Reasoning: use plain language, avoid promising that warfarin is finished, correct the assumption without overloading her, and give a specific safety-netting instruction. The answer should reflect uncertainty honestly rather than guessing.