title: Adverse events and deaths associated with laboratory errors at a hospital--Pennsylvania, 2001.
abstract: On August 3, CDC was contacted by the Pennsylvania Department of Health (PADOH) to assist with an investigation of laboratory errors that may have contributed to the deaths of two persons taking the anticoagulant drug warfarin (Coumadin) (DuPont Pharmaceuticals Company, Wilmington, Delaware). The Food and Drug Administration (FDA) also is conducting an investigation of these incidents. Warfarin inhibits blood clotting and is prescribed for the management and prevention of conditions such as strokes, clots in the veins, and heart attacks. Physicians routinely monitor warfarin's anticoagulation effect on the blood by following two laboratory results: the prothrombin time (PT) and the International Normalized Ratio (INR). The INR is a numeric value calculated from the PT; the World Health Organization recommends the INR to standardize PT results from various manufacturers' devices and testing reagents. Physicians use INR to compare test results performed at different laboratories.
mesh_terms: D006801:Humans; D019934:International Normalized Ratio; D007755:Laboratories, Hospital; D019300:Medical Errors; D010414:Pennsylvania; D017751:Safety Management; D014859:Warfarin / Q000008:administration & dosage*
chemical_list: D014859:Warfarin