Failure to Resume Anticoagulant Results in Significant Medication Error and Hospitalization
Penalty
Summary
A significant medication error occurred when a resident with a history of pulmonary embolism and deep vein thrombosis was not administered Eliquis, an anticoagulant, as ordered by the physician. The resident was readmitted to the facility with orders to hold Eliquis for a specified period due to a scheduled polyp removal. There were two separate physician orders: one to hold Eliquis until a certain date without a restart date, and another to hold the medication for four days and restart on a specific date. The orders conflicted, and the facility's electronic system placed the medication on hold indefinitely due to the lack of a clear restart date in one of the orders. As a result of this error, the resident did not receive Eliquis for an extended period. The medication administration record (MAR) showed that Eliquis was not given from the time of readmission through the following month, with the medication remaining on hold. The facility failed to reconcile the conflicting orders and did not ensure that the medication was restarted as required by the physician's instructions. This lapse in medication administration was not identified or corrected in a timely manner. The resident was subsequently hospitalized with a diagnosis of noncompliance with Eliquis, presenting with syncope and found to have acute pulmonary embolism and right lower extremity DVT, requiring surgical intervention. The failure to administer Eliquis as ordered directly led to the resident's hospitalization and significant harm. The deficiency was identified as Immediate Jeopardy, with the noncompliance period beginning when the resident was hospitalized and ending after corrective actions were implemented.