Medication Transcription Error for Anticoagulant Order
Penalty
Summary
Facility staff failed to ensure that a medication order for an anticoagulant met professional standards of quality when a nurse inaccurately transcribed a physician’s order for apixaban. The resident involved had been admitted after an acute care hospital stay with diagnoses including right 5th finger osteomyelitis/septic arthritis requiring IV therapy, congestive heart failure, and atrial fibrillation, and had a BIMS score of 11/15 indicating moderately impaired cognitive abilities for daily decision-making. The resident was admitted with an order for apixaban 2.5 mg by mouth twice daily. A new order was written on 3/13/26 for apixaban 2.5 mg, but it was transcribed in the record as “Give 12.5 mg by mouth twice daily,” changing the dose from 2.5 mg to 12.5 mg. On 3/14/26, a nurse signed off that 12.5 mg of apixaban had been administered, reflecting the incorrect transcribed dose. The physician’s progress note from 3/13/26 documented that the resident had presented with new left leg swelling and redness and had undergone an ultrasound to rule out a blood clot, which was negative, but there was no order from the physician to increase apixaban to 12.5 mg. During an interview, the ADON stated that the nurse who transcribed the order mistakenly changed the apixaban dose and that the nurse who administered the medication did not notice that the new ordered dose would have equaled five tablets instead of one. The ADON further stated that an audit later showed that the 12.5 mg strength was associated with a new order for Aldactone, not apixaban, confirming that the transcription error had occurred in the medication orders for this resident.
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