Failure to Prevent Significant Medication Error: Missed Immunosuppressant Doses
Penalty
Summary
A resident with a history of heart transplant, heart failure, and stroke was readmitted to the facility following a hospitalization for heart failure exacerbation. Upon discharge from the hospital, the resident was prescribed tacrolimus, an immunosuppressant medication, with a revised dosing schedule. The facility's medication reconciliation process identified potential clinically significant medication issues, but the documentation did not specify the discrepancies or their resolutions. An order for tacrolimus was entered into the physician's orders but was subsequently discontinued the same day, resulting in the resident not receiving any tacrolimus from the following day until nearly three weeks later. During this period, the resident missed 40 doses of tacrolimus. Progress notes and medication records failed to document the discontinuation or provide a rationale for stopping the medication. Multiple staff, including the physician and physician assistant, did not identify the omission of tacrolimus in the resident's regimen, despite reviewing the medication list and being aware of the resident's transplant status. The facility's pharmacy consultant also reviewed the medication regimen during this time and did not note any irregularities. Communication breakdowns were evident, as the resident's cardiology team repeatedly attempted to obtain updated medication lists and lab results from the facility but encountered significant barriers and delays. The error was ultimately discovered when the cardiology team noted a critically low tacrolimus level and contacted the facility, at which point it was confirmed that the resident had not received the medication. The resident required emergent hospitalization for rejection surveillance and medication adjustments. Interviews with facility staff revealed a lack of awareness regarding the discontinuation of tacrolimus and a failure to identify or address the medication error until notified by the external cardiology team.