Concurrent Administration of Warfarin and Eliquis Due to Failure to Discontinue INR Testing and Medication Review
Penalty
Summary
A deficiency occurred when a resident with a history of atrial fibrillation, congestive heart failure, type II diabetes mellitus, and chronic kidney disease was prescribed and administered two anticoagulant medications, Warfarin and Eliquis, concurrently. The resident was originally on Warfarin, which was discontinued following a hospital procedure, and Eliquis was started per hospital orders. However, the facility continued to perform INR testing, which is only indicated for Warfarin therapy, not Eliquis. On receiving a low INR result, the facility communicated this to the Coumadin Clinic, which, unaware that the resident was now on Eliquis, ordered Warfarin to be restarted. As a result, the resident received both Warfarin and Eliquis for several days. Medication administration records showed that drug interaction warnings were triggered each time both anticoagulants were administered, but the orders were not reviewed or questioned by facility staff during this period. The error was discovered when a nurse noticed the concurrent administration of both anticoagulants after an elevated INR result was obtained. The facility's daily clinical review process failed to identify the inappropriate orders due to the absence of the Director of Nursing during that week. Interviews confirmed that the facility should have discontinued INR testing after Warfarin was stopped and that the Coumadin Clinic had access to the updated medication list but did not verify it before issuing new orders.