Warfarin-induced tissue necrosis is a rare and serious side effect associated with warfarin treatment. A case study of a patient with warfarin-induced tissue necrosis taken from clinical practice illustrates the importance of timely diagnosis and treatment to avoid the devastating consequences of this adverse drug reaction. Nurse prescribers must be alert to and aware of potential adverse drug reactions that may be caused by any prescribing decision, and should be able to take appropriate action when such an event occurs.