Significant Medication Error in Warfarin Administration and Monitoring
Penalty
Summary
A significant medication error occurred when a resident with a history of hypertension, kidney disease, diabetes, stroke, and left-sided paralysis was administered warfarin, a blood-thinning medication, twice daily instead of the prescribed once daily at bedtime. The resident was admitted from the hospital with orders for warfarin and regular INR (international normalized ratio) monitoring to manage stroke risk. The initial physician's order specified warfarin 1 mg in the morning, with daily INR monitoring for dose adjustments. After an INR result was communicated to the physician, a new verbal order was given for warfarin 1.5 mg to be administered once daily in the evening, along with instructions to document the most recent INR and schedule the next INR test. However, the verbal order did not include discontinuation of the previous morning dose, resulting in the resident receiving both the morning and evening doses of warfarin from August 28 to September 9. During this period, facility nurses failed to update the medication administration record (MAR) with the most recent INR result from August 26, instead repeatedly documenting an outdated hospital INR result from August 22. The scheduled INR test for August 29 was not completed, and the error in warfarin administration continued until a subsequent INR test on September 10 revealed an elevated level of 4.5. The facility's medication administration policy required medications to be given as prescribed and for staff to contact the prescriber if a dosage appeared inappropriate or excessive. The anticoagulation protocol also required the use of a warfarin flow sheet to track dosage and response. Despite these policies, the failure to discontinue the prior warfarin order, lack of accurate INR documentation, and omission of scheduled INR testing led to the resident receiving excessive doses of warfarin over a prolonged period.