Medication Reconciliation Failure Leads to DVT
Penalty
Summary
A significant medication error occurred when a resident with a history of right femur fracture, muscle weakness, anxiety, and atrial fibrillation was discharged from the hospital with an order for Enoxaparin 40 mg subcutaneously every 24 hours for 30 days to prevent blood clots. Upon admission to the facility, the medication was transcribed incorrectly, and the resident received Enoxaparin for only 10 days instead of the prescribed 30 days. The medication administration record reflected this shortened duration, and three licensed nursing staff administered the medication over the 10-day period. The facility's medication reconciliation policy required verification of orders and clarification with the transferring hospital if discrepancies were found, but this process was not properly followed. The error was discovered after the resident developed pain, redness, and swelling in the thigh, leading to an emergency department transfer where a deep vein thrombosis (DVT) was diagnosed by ultrasound. Interviews with facility staff revealed that the order was not checked a second time as required, and the nurse responsible for transcribing the order was unclear about the process and did not ensure a proper handoff. The Director of Nursing confirmed that the usual double-check process was not completed due to the absence of the unit clerk, resulting in the medication error and subsequent adverse event.