Failure to Identify and Report Methotrexate Dosing Irregularity During Pharmacy Review
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the consulting pharmacy identified and reported a significant medication irregularity involving Methotrexate dosing for a newly admitted resident. The resident’s hospital discharge orders specified Methotrexate 2.5 mg, four tablets in the morning and three tablets in the evening, to be given once weekly. When the orders were transcribed at the facility, the Methotrexate frequency was incorrectly entered as once daily instead of once weekly, and these incorrect orders were sent electronically to the pharmacy. The pharmacy filled the Methotrexate as written on the incorrect daily orders. During the monthly drug regimen review for new admissions, the pharmacist did not identify the Methotrexate order as an irregularity, despite the EMR’s MAR dose warning indicating that the entered dose and daily frequency were outside the recommended regimen of one to ten tablets every seven days. Interviews with pharmacy personnel confirmed that two pharmacists reviewed and approved the order without recognizing the incorrect frequency, and the pharmacist in charge attributed the failure to human error. The resident had diagnoses including rheumatoid arthritis, dysphagia, metabolic encephalopathy, atrial fibrillation, and congestive heart failure, and was assessed as cognitively intact with moderate assistance needs for ADLs. Following the incorrect daily administration of Methotrexate, the resident developed thrush and later became neutropenic with altered respiratory status, as reflected in revisions to the resident’s care plan. Hospital records for a subsequent hospitalization documented admission for neutropenic fever, Methotrexate toxicity, and sepsis, during which the Methotrexate medication error was discovered. The resident required intubation and ICU care and ultimately expired after extubation.
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