by Rachel Pollock, Marketing and Brand Specialist, and
Karen Werth, MBA, CPHRM, Senior Risk Management Representative
A 75-year-old woman was admitted to a rehabilitation hospital after experiencing weakness and an increased number of falls at home. The patient had a history of coronary artery disease, congestive heart failure, sick sinus syndrome (SSS), and long-time use of anticoagulation and antiplatelet medications. The hospital documented her medications as rivaroxaban and/or warfarin to treat atrial fibrillation. She was also taking clopidogrel as an antiplatelet. After 15 days, she was discharged.
Approximately one year later, on July 16, the patient was re-admitted to the rehabilitation hospital following a series of falls. Information about her medications was provided to the hospital by the patient’s spouse and home health nurse two days before admission.
Upon admission, the attending hospitalist conducted a physical exam and reviewed the patient’s history. He documented his findings in the hospital’s electronic health record (EHR). The EHR included a section for medications that pre-populated her medications before the exam was conducted. The listed active medications did not include any anticoagulant or antiplatelet drugs.
The physician noted that the patient “had increasing weakness over the past several weeks associated with atrial fibrillation.” His notes also indicated that the patient had multiple issues that required close monitoring including chronic obstructive pulmonary disease, congestive heart failure, back pain, spinal stenosis, and recent falls.
Daily progress notes showed that the patient’s atrial fibrillation was well controlled. On July 21, the patient experienced an episode of hallucinations but was otherwise alert and oriented. The hospitalist ordered the administration of clopidogrel, and the patient received her first dose on July 22.
On July 23, the patient began to exhibit weakness and impaired movement. The patient had a stroke that evening.
She was transferred in critical condition to a nearby hospital. A head CT showed an occlusion of the M2 segment of the left middle cerebral artery. The patient also exhibited altered mental status, inability to speak, and focal weakness on the right side. She died in the hospital two days later.
The patient’s family filed a lawsuit against the hospitalist. The allegations included failure to prescribe an oral anticoagulant and an antiplatelet medication which led to the patient’s injuries and death.
An expert consultant for the plaintiff stated that the hospitalist breached the standard of care when he failed to review the patient’s history and medication profile and compare it to what was reported by the patient’s spouse and home health nurse on July 16. He failed to reconcile medications and prescribe anticoagulants to prevent stroke in a patient with atrial fibrillation.
Defense consultants were also critical of the physician’s care of the patient. One consultant noted the lack of documentation, stating that the hospitalist should have noted the significant medication discrepancy in the patient’s medication records.
Another consultant for the defense stated that it would have been appropriate for the hospitalist to document or question the omitted anticoagulant and antiplatelet medications from the patient’s list of medications. This consultant added that the documentation also lacked reasoning for starting the clopidogrel, as there were no documented events that would prompt adding this medication.
The case was settled on behalf of the hospitalist.
Risk management considerations
Harm to patients can occur when medications are improperly prescribed, prepared, or dispensed; incorrectly entered into a computer system; or taken incorrectly by patients. Medication errors may involve prescription drugs, over-the-counter medications, vitamins, and even supplements. Consequences can be very serious. According to research, 7,000 to 9,000 people die annually in the United States due to medication errors. (1)
Types of medication errors include:
- prescribing errors;
- omission or failure to prescribe, administer, or dispense a medication;
- providing a patient with a medication too late or prematurely;
- giving an unauthorized drug to a patient;
- improper use of a medication;
- wrong dose prescription/preparation;
- administration errors, including giving a drug to the wrong patient, extra dosing, or using the incorrect route of administration;
- monitoring errors, such as failing to acknowledge a patient’s medical conditions or potential drug interactions; and
- failing to follow proper dispensing/prescribing protocols for a medication. (1, 2)
In this case, the anticoagulant and antiplatelet medications were omitted in the EHR. If a medication is omitted, changed, or discontinued, physicians should document their treatment rationale. In this case, nothing was documented about the cessation of anticoagulants due to the patient’s risk of falling.
Hospital EHRs have a section for documentation of patients’ home or outpatient medications. When information is difficult to obtain due to patient status or lack of family or caretakers, steps may be taken to contact outpatient physicians. Ideally, the information should include the name of the medication, dosage, start date, and name of the prescriber. Obtaining complete information – whenever possible – may reduce the chances of duplications, omissions, or incorrect dosages.
Unfortunately, in this case the patient’s medications were not thoroughly reviewed or reconciled. Hospitals should have protocols in place to ensure all medications prescribed and taken at home are included in the medical record. Maintaining good policies on reconciliation and review of all medications being taken by a patient can help avoid medication errors.
1. Sison G. 5 ways to prevent common pharmacy errors. The Checkup blog. SingleCare website. June 16, 2022. Available at https://www.singlecare.com/blog/pharmacist-errors-and-mistakes/. Accessed August 29, 2022.
2. Medication errors statistics 2022. The Checkup blog. SingleCare website. Updated January 20, 2022. Available at https://www.singlecare.com/blog/news/medication-errors-statistics/. Accessed August 29, 2022.
Rachel Pollock can be reached at email@example.com.
Karen Werth can be reached at firstname.lastname@example.org.