Medication Transcription Error Resulted in Incorrect Anticoagulant Dosing
Penalty
Summary
A deficiency occurred when a resident was admitted to the facility with hospital discharge orders for Apixaban 5 mg to be administered twice daily, once in the morning and once at bedtime, for atrial fibrillation. The Assistant Director of Nursing (ADON) transcribed the order incorrectly into the facility's Medication Administration Record (MAR) as Apixaban 5 mg once daily, resulting in the resident receiving only half the prescribed dose for 34 days. The facility physician signed off on the transcribed order without documentation indicating awareness of the original hospital order or an intentional change in dosage. There was also no documentation that the resident's Power of Attorney (POA) was notified of the change in medication dosage. Interviews with facility staff revealed that the process for entering and double-checking new admission orders lacked documentation of a secondary review. The Unit Manager Registered Nurse (UMRN) confirmed that while orders were supposed to be double-checked by another administrative nurse, there was no place in the electronic medical record to document this verification. The ADON acknowledged the error in transcription and stated that the order should have been entered as twice daily, as per the hospital discharge summary. Further review of physician progress notes and interviews indicated that the physician reviewed and reconciled the medication list as it appeared in the facility's MAR, which already contained the transcription error. There was no evidence that the physician compared the facility's orders to the hospital discharge summary or that any intentional change to the Apixaban dosage was made. As a result, the resident received an incorrect dose of a critical anticoagulant medication throughout their stay.