Failure to Reconcile Medication Orders Leads to Significant Medication Error
Penalty
Summary
The facility failed to ensure accurate medication reconciliation for a resident following a hospital discharge, resulting in the administration of nine additional doses of Eliquis (apixaban) beyond what was ordered by the physician. The resident, who had a history of osteomyelitis and had recently undergone a left knee fusion, was prescribed Eliquis 2.5 mg twice daily for 30 days. Upon review, it was found that the medication order was entered twice into the electronic Medication Administration Record (eMAR), leading to duplicate administrations of the anticoagulant. The facility's policies required that medication reconciliation be performed at admission and after hospitalizations, with orders compared to hospital records and verified by a second nurse. However, these procedures were not followed, as the duplicate order was not identified during the initial review or subsequent daily clinical meetings. Multiple nurses administered the medication as documented in the eMAR, and none questioned the duplicate orders or documented any concerns. The error was only discovered after a surveyor brought it to the attention of the unit manager. Additionally, the facility's policy mandated immediate reporting and investigation of medication errors, including completion of a medication error report and notification of supervisory staff. In this case, although the unit manager and assistant director of nursing were made aware of the error, no medication error report was completed, and no formal investigation or documentation of the incident occurred. The director of nursing confirmed that the required protocol for medication error reporting and investigation was not followed.