A resident with a history of pulmonary embolism did not received prescribed Coumadin and did not have her INR blood level checked that could have revealed the issue and prevented the problem from occurring. This resulted in the resident being admitted to the hospital with a pulmonary embolism and receiving Heparin via an intravenous drip.
The facility staff recognized the medication and laboratory errors, and actions were taken to prevent this error from recurring. Staff should review the latest version of the State Operations Manual (SOM), Appendix PP, that addresses “thromboembolism related to use of antithrombotic medication” as a “Potentially Preventable Event” according to the list developed through the collaboration between the Centers for Medicare and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ). According to the SOM, F867, QAPI/QAA Improvement Activities, facilities are required to conduct performance improvement activities involving high-risk, high-volume, problem-prone area(s) as part of the program. to uncover root cause in order to determine the necessary steps to prevent a recurrence of a similar error.
Paula Revere Alert
QAPI Case Study
Medication Error
I. Risk Exposure:
resident was admitted on 10/20 with a one-time medication order for 5 mg of Coumadin and an order to have her INR checked. The recheck was not done because the resident was at dialysis at the time, and neither nurse on duty was aware that the lab was not done. On 10/21 the nurse who signed off the alert wrote—INR 2.2, but no Coumadin. The check off for labs on 10/24 indicated there was no Coumadin order. There was a notification made on 10/23 that 5 mg. of Coumadin was given.
II. Potential Reason/Root Cause:
A resident with a history of pulmonary embolism did not receive prescribed Coumadin and did not have INR labs checked that could indicate a problem.
III. Quality Assurance Mitigation Strategy (QA):
A staff member was reading about the omission and started an investigation. Lab work was completed, and the INR was 1.2, then an order for 6 mg. of Coumadin for 3 days was given. The facility
is attempting to contact the nurse who was on duty that weekend and who did not check for the order. The 6 mg. of Coumadin was administered to the resident. The supervisor called the staff member doing the investigation because the resident’s O2 was down. The resident was given oxygen, but her oxygen level did not improve, so she was transferred to the hospital on 10/25. She was admitted with a pulmonary embolism and is on a Heparin drip. She is currently stable. All nurses were called who were involved. The nurse who discovered and identified the discrepancy was pulled, and the nurse who did not give the Coumadin was written up. The physician noted that the resident has a history of pulmonary embolisms and noted that there was nothing in the resident’s chart to indicate that she had a filter. He noted that the staff should be aware that taking a resident off Coumadin for dental or other reasons should be monitored, and if their INR drops down, the standard of care practice is to start an anticoagulant IV until the count goes up. For Coumadin, this takes 5 to 7 days and that is why the anticoagulant bridge is important when INR is 1.5.
IV. Potential F-Tags:
F332/F759 Free of Medication Error Rates of 5% or more
F502/F503/ F770 Laboratory Services
V. Performance Improvement/Education (PI):
Facility will review all books to ensure that no one else was affected. A review of the red Coumadin books will be completed daily. Supervisors will be made aware and have a list of INR tests over the weekend. All staff will receive education regarding documentation of the Coumadin flow record. All should be alert to the possibility of a MAR error when Coumadin is being given, and make sure that there is a valid order in place if a resident taking Coumadin is put on hold. If a new order is given, the Coumadin book must be updated. If the resident is on antibiotics, the INR checks must be increased. The facility will issue this standard alert to staff: Check order for requested labs for a resident on Coumadin. Indicate whether an order is present by noting Yes or No
