Significant Medication Error Leads to Hospitalization Due to Missed Anticoagulant
Penalty
Summary
A deficiency occurred when a resident was not administered a prescribed anticoagulant medication, Apixaban, upon admission to the facility. The resident had a complex medical history, including a recent femur fracture, Type 2 Diabetes Mellitus, cerebral infarction, peripheral vascular disease, anemia, and atrial fibrillation. The hospital discharge summary listed Apixaban as one of the medications to be continued, but a review of the clinical record and medication administration record revealed that there was no physician's order or documentation of Apixaban being administered from the date of admission through several days after. The omission resulted from a transcription error during the medication reconciliation process. A registered nurse assisting with multiple admissions noted a confusing instruction on the hospital discharge summary regarding Apixaban, which stated to "resume" the medication on a specific date. The nurse communicated this concern to the LPN on duty and instructed them to follow up, but the LPN did not do so, and the medication was not entered into the system. As a result, the resident missed ten days of Apixaban therapy. The resident subsequently developed a cold, pulseless left foot and was evaluated by a physician, who recommended an immediate arterial doppler. Due to the unavailability of a technician, the resident was transferred to the hospital, where they were diagnosed with a popliteal artery embolism and underwent a thrombectomy. The omission of Apixaban was identified during a readmission review, confirming that the medication error had compromised the resident's clinical condition and resulted in actual harm requiring hospitalization.