Missed Warfarin Doses Result in Significant Medication Error
Penalty
Summary
A significant medication error occurred when an eighty-two-year-old male resident with a history of peripheral vascular disease and pulmonary embolism did not receive prescribed doses of Warfarin, a blood thinner, over a four-day period. The resident's medical records showed that on 3/24/25, the primary care physician ordered continuation of Warfarin 3mg after reviewing Protime/INR results. However, this order was not entered into the Medication Administration Record (MAR), resulting in the resident missing four consecutive doses from 3/24/25 through 3/27/25. The next Warfarin order was not entered until 3/28/25, and there was no documentation of a physician order or lab result for that date. Staff interviews confirmed that Warfarin administration requires close monitoring with lab draws and that missing doses increases the risk of blood clots. The Director of Nursing acknowledged that the Warfarin order was not continued during the missed period, and the resident did not receive the medication as prescribed. The facility's policy requires medications to be administered according to established procedures, which was not followed in this instance.