Significant Medication Error: Held Anticoagulant Administered
Penalty
Summary
A significant medication error occurred when a Licensed Practical Nurse (LPN) administered Coumadin 2mg to a resident despite a physician's order to hold the medication due to an elevated International Normalized Ratio (INR) of 3.3. The order to hold Coumadin was documented earlier that day, but the LPN administered the medication during the evening medication pass. The resident had a medical history including atrial fibrillation, cervical disc degeneration, congestive heart failure, and pulmonary edema, and was receiving anticoagulant therapy. Following the administration of the held medication, the resident's INR increased to 7.9, and the resident required immediate administration of Vitamin K as per physician's orders. Interviews revealed that the LPN acknowledged seeing the physician's order to hold the medication but administered it by mistake, citing being overwhelmed and working alone. The facility's policy defines a medication error as any event that may cause or lead to inappropriate medication use or resident harm, including administering a medication that has been held. Other staff interviews indicated that while nurses receive reports about medications on hold or discontinued, it is their responsibility to check electronic health records and physician orders prior to administration. The Director of Nursing confirmed that nurses are expected to follow physician orders and adhere to the five rights of medication administration.