Concurrent Administration of Warfarin and Eliquis Resulting in Significant Medication Error
Penalty
Summary
A significant medication error occurred when a resident with a history of atrial fibrillation, congestive heart failure, type II diabetes mellitus, and stage III chronic kidney disease received two anticoagulant medications, Warfarin and Eliquis, concurrently. The resident had been on Warfarin since admission, with regular INR monitoring and dosage adjustments. Following an elective surgical procedure, hospital discharge instructions discontinued Warfarin and initiated Eliquis, and the facility updated orders accordingly. However, INR testing continued despite the switch to Eliquis, which does not require such monitoring. Subsequently, when a low INR result was reported to the Coumadin Clinic, new orders were given to restart Warfarin without discontinuing Eliquis, resulting in both anticoagulants being administered simultaneously. The medication administration records confirmed that the resident received both Warfarin and Eliquis over several days. Drug interaction warnings were triggered in the medication administration system, but the orders were still processed and administered. The pharmacy was aware of the duplicate anticoagulant therapy but did not clarify the order with the facility before dispensing the medications. Multiple staff interviews revealed that the error was not identified until a nurse noticed the concurrent administration of both anticoagulants after a high INR result. The facility's daily clinical review process failed to catch the error due to the absence of the Director of Nursing. The Coumadin Clinic and hospital staff also did not verify the current medication list before issuing new orders. The resident did not recall receiving both medications and did not experience any adverse outcomes during the incident.