A 67-year-old man with atrial fibrillation is anticoagulated with warfarin. He visits three different clinics for medication refills and has labs drawn at each site, but results are not integrated in a unified EHR system. One clinic increases his warfarin dose without knowledge of a recent INR of 4.2 obtained at another clinic. He develops a hemorrhagic stroke. Which quality and safety concept does this exemplify?

1. A)Inadequate laboratory testing for INR monitoring in anticoagulation
2. B)Patient non-adherence from visiting multiple clinics without coordination
3. C)Fragmentation of care due to lack of interoperable health information systemsGABARITO
4. D)Provider knowledge deficit regarding warfarin dosing in elderly patients
5. E)Medication error from provider misreading of the prescription label