Failure to Transcribe and Administer Physician-Ordered Anticoagulant
Penalty
Summary
A significant medication error occurred when a physician-ordered anticoagulant, Coumadin, was not transcribed into the facility's electronic medical record for a resident who had recently undergone left femur fracture surgery (ORIF) and had multiple high-risk cardiac diagnoses, including atrial fibrillation and cardiomyopathy. The hospital discharge instructions specified that Coumadin therapy should be continued, with a detailed dosing schedule, and the medication was delivered to the facility and available for administration. However, the Coumadin order was not entered into the Physician Order Sheet upon admission, resulting in the medication not appearing on the Medication Administration Record (MAR) and not being administered by nursing staff. The error was traced to an LPN who admitted the resident and failed to transcribe the Coumadin order, citing confusion regarding the dosing schedule. This omission was not identified by subsequent nursing staff, as there was no verification or follow-up on the admission orders or discharge instructions. As a result, the resident missed 14 consecutive days of prescribed anticoagulation therapy. The error was only discovered when the medical director, during rounds, noticed the absence of anticoagulation therapy and intervened. Documentation from the facility's pharmacy confirmed that the Coumadin prescription matched the hospital discharge orders and was available for use. The medical director and pharmacist both acknowledged that the missed doses posed a significant risk to the resident, given their recent surgery and underlying cardiac conditions. The incident was recorded in the facility's Quality Assurance report, which also noted an additional transcription error regarding the Coumadin dosing schedule.