Health and Disability

The analysis of government inspection reports found that, between 2011 and 2014, at least 165 nursing home residents were hospitalized or died after errors involving Coumadin or its generic version, warfarin. In some cases, homes gave residents too much of the drug, which caused internal bleeding. In other cases, they gave residents too little, leading to blood clots and strokes.

ProPublica’s findings “highlighted the adverse effects of poor Coumadin management for our beneficiaries and nursing home stakeholders,” Thomas Hamilton, director of CMS’ survey and certification group, said in a written response to questions from ProPublica. “We wanted the public to have confidence that CMS is aware of this as well as other high risk medications.”

In its July 17 memo, CMS – the federal agency that regulates nursing homes – also told state health departments that inspect nursing homes on its behalf about a new tool for identifying and reducing medication errors. The tool, developed with the Agency for Healthcare Research and Quality, is designed to help determine whether nursing homes are taking adequate steps to prevent mistakes and whether they respond appropriately if they occur.

Although Coumadin has clear benefits and is life-saving for those taking the right dose, a number of peer-reviewed studies suggest that it is can be dangerous if not closely monitored. A 2007 study in The American Journal of Medicine estimated that nursing home residents suffer 34,000 fatal, life-threatening or serious events each year related to the drug.