Failure to Transcribe Warfarin Order Results in Missed Doses and Serious Harm
Penalty
Summary
A significant medication error occurred when a resident with a mechanical heart valve and a high risk for deep vein thrombosis (DVT) did not receive prescribed anticoagulant therapy for seven days. The resident had a physician's order for warfarin, with dosing adjustments based on PT/INR lab results, and required close monitoring to maintain a therapeutic INR range of 2.5 to 3.5. On a specific date, a nurse received a verbal order to restart warfarin at a new dose and to recheck the INR on a later date. However, the nurse failed to transcribe this order into the electronic medical record (EMR) and the medication administration record (MAR), resulting in the resident not receiving warfarin for an extended period. This omission was not identified until another nurse noticed the absence of a current warfarin order and a critically low INR level. The resident's INR dropped to 0.97, indicating subtherapeutic anticoagulation. During this period without anticoagulant therapy, the resident developed a blood clot in the right leg, which ultimately led to an above-the-knee amputation. The facility's records and staff interviews confirmed that the missed transcription of the physician's order directly resulted in the failure to administer the medication as prescribed. The resident's medical history included atrial fibrillation, a mechanical heart valve, recurrent DVT, and significant immobility, all of which increased the risk for thromboembolic events. Documentation showed that the resident required assistance with most activities of daily living and had a care plan in place for anticoagulant therapy. The error was traced to a breakdown in the process of entering and verifying physician orders, as well as a lack of timely recognition by staff that the medication had not been administered.