Francis Abbott is a 72 year old retiree who lives independently in her own home.  She has type II diabetes mellitus and has recently been diagnosed with atrial fibrillation. 

On April 21 she goes to her local pharmacy to have her prescriptions refilled.  She receives her medications and returns home.  A week later she awakens at 05:15 with abdominal cramping and has a bloody stool when she goes to the toilet.  She feels light headed, her symptoms continue and she calls 911. 

Francis is taken to the ED for treatment and her daughter is called.  Francis's daughter Sarah brings her mother's medications from home and it is found that she has two strengths of Warfarin and the 5 mg tablets are in a container labelled Coumadin 1mg and the 1mg tablets are in a container labelled Coumadin 5mg.  It is determined that Francis has been taking 16mg of Warfarin daily rather than her most current prescribed dose of 8mg daily.  Francis is treated in hospital and is discharged two days later with no further symptoms. 

End Case Summary

PHASE 1: GATHER INFORMATION 

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