Significant Medication Error Due to Incorrect Methotrexate Transcription
Penalty
Summary
A significant medication error occurred when a resident with complex medical conditions, including Antiphospholipid Syndrome and CREST syndrome, was admitted to the facility. The resident's hospital discharge summary specified that Methotrexate, an oral chemotherapy agent with a black box warning, was to be administered as 10 tablets (25 mg) once weekly, divided into morning and evening doses. However, upon admission, nursing staff inaccurately transcribed the order into the electronic medical record, resulting in the medication being scheduled and administered as 5 tablets twice daily, every day, rather than once weekly as intended. The error went undetected by multiple staff members, including the admitting nurse, the reviewing physician, and the nurse practitioner, all of whom either entered or reviewed the orders without recognizing the incorrect frequency. The nurse who entered the order admitted unfamiliarity with Methotrexate dosing, and the nurse practitioner stated that Methotrexate was managed by specialists and did not question the listed frequency. As a result, the resident received excessive doses of Methotrexate over several consecutive days. Following the administration of Methotrexate at the incorrect frequency, the resident experienced a decline in condition, including acute respiratory distress, decreased oxygen levels, gastrointestinal symptoms, and reduced intake. The resident was transferred to the hospital, where laboratory findings confirmed toxic levels of Methotrexate and pancytopenia, consistent with chronic Methotrexate toxicity. The facility's Director of Nursing and Medical Director acknowledged that the medication reconciliation and transcription process was not performed in accordance with facility protocol, leading to the significant medication error.