Failure to Identify and Report Methotrexate Dosing Error
Penalty
Summary
A deficiency occurred when a facility failed to ensure that a licensed pharmacist performed an adequate monthly drug regimen review, including a review of the medical chart, and failed to identify and report a medication prescribed and administered at an excessive frequency. Specifically, a resident with diagnoses of Antiphospholipid Syndrome and CREST syndrome was admitted with a hospital discharge order for Methotrexate 25 mg to be given once weekly. However, due to a transcription error by a nurse, the medication was entered into the electronic medical record to be administered daily instead of weekly. The error was not detected by the dispensing pharmacist, who overrode a Drug Utilization Review (DUR) alert without verifying the order with the facility, nor by the pharmacy consultant during the interim medication regimen review. As a result, the resident received Methotrexate at a daily dose for several days, far exceeding the recommended frequency. The facility's policy required the pharmacist to identify, evaluate, and address medication-related issues, but this process failed at multiple points, including order entry, pharmacy review, and consultant pharmacist oversight. The resident subsequently experienced an acute decline in condition, including respiratory distress, decreased oxygen levels, loose bowel movements, and decreased intake, leading to hospital transfer. Hospital records indicated the resident developed pancytopenia likely due to chronic Methotrexate toxicity, with toxic drug levels confirmed. The failure to identify and report the medication error in a timely manner directly contributed to the resident's adverse outcome.