Case Study - Medication Incident
Background: The scenario takes place in a community with a hospital and busy home care service. The hospital faxes new and updated home care referrals to a central fax line. The referral form provides demographic patient information, diagnosis, a list of discharge medications and physician orders for home care. Monday to Friday during business hours, a Home Care Coordinator reviews the faxed document and accesses the Home Care Central Record for any existing clients. The Coordinator then reviews the information in the documents and schedules the applicable home care visits. After business hours and on weekends, the home care nursing staff periodically checks the faxes, and sorts them by ongoing clients or new clients. Referrals updating the status of ongoing clients are given directly to one of the nurses responsible for that geographic area of the community. Pharmacists and technicians dispense medications from the drug stores in the community. Technicians are responsible for processing prescriptions in the computer and preparing and labelling medications as well as inventory management functions. Pharmacists are responsible for reviewing the patient medication profile and completing the final check of the medications before they are dispensed for pick-up or home delivery. Some attending physicians at the Community Hospital fax a prescription to the patient’s drug store so that patients and families can easily pick-up any needed medications on the way home. The incident involves a 76-year-old male home care client receiving a leg ulcer dressing change every five to seven days. The patient is obese and has a history of angina, high blood pressure and deep vein thrombosis. He has limited mobility and was in hospital for eight days with a diagnosis of community-acquired pneumonia. The patient was discharged on a Saturday with a referral sent through the Home Care fax line to advise of his return home. His list of medications were noted on the form as: Nifedipine 10 mg TID (calcium channel blocker), Atenolol 50 mg BID (beta blocker), Coumadin 2 mg OD (anticoagulant), ASA 81 mg OD (antiplatelet), doxycycline 100mg OD x 6 days (antibiotic), nitrospray prn and DuoDERM® dressing to leg ulcer weekly. Additional background information: patient was weak and slightly short of breath at discharge.

My Community Home Care Service Patient Safety Incident Report
Home Care Date of Event: Any day Time of Event: 1400 hrs Client Identification (Name, Age, Gender) N000321 Clayton Phillips, 82 yrs. 77 Anystreet, Anytown, Canada Dr. E Smith

Event Description: Client was found in bathroom by RN on arrival at 0900 for dressing change. Moderate amount of bright red blood in toilet and floor. Ambulance called and transferred to Emergency Dept. Reporter just called ED and spoke with Charge Nurse. Patient’s INR 5.8. Upon review of medication bottles it was determined that patient was unintentionally taking 5 mg of Warfarin daily as he did not know that Coumadin was the same medication as Warfarin so took “previously” ordered dose of 3 mg (Warfarin) and “newly” prescribed dose of 2 mg (Coumadin) as well. Type of Error:  Omission  Wrong Rate  Technique  Expired X Dosage  Wrong Conc / Strength  Wrong patient  Wrong Drug  Wrong Route  Wrong Time  Monitoring Error (e.g. sliding scale, allergy missing)  Narcotic Count Discrepancy X Dispensing / Delivery  Monitoring

Discovered By:  LPN  RPN X RN  Pharmacist  Pharmacy Tech  MD  Other

Other type (describe):

Stages Involved:  Physician Ordering  Transcription X Administration / Documentation Name of Drug(s) / Product(s) / Route / Strength:

(Check all that apply) Number of doses involved: 5

Drug ordered: Coumadin 2 mg OD Drug received: Warfarin/Coumadin 5 mg OD due to error in taking medications from two bottles (Coumadin and Warfarin) Patient - Relevant information or interventions taken for this resident.  Check none necessary or describe: Client transferred to ED by ambulance. Admitted to Medicine Unit. Outcome:   X   Good Catch No Harm Harm (Required extra monitoring or interventions) Harm Major / Sentinel Event (Notify Manager or delegate immediately) Death X Yes Date: Date discovered Time: 0900  Next Visit

Notification Primary Physician notified?

Patient Informed?  Yes Date: __________________ Time: _________ X No Family Notified?  Yes Date: __________________ Time: _______ X No

Incident Analysis Simulation: Medication Incident - Final Timeline Item Comment/Source Client receiving weekly home care visit by RN for leg ulcer dressing change every five to seven days for approximately six weeks. Occasionally forgetful about caring for dressing and short-term memory mildly impaired however able to manage own medications. Friday - 14 RN makes home visit to change client’s leg dressing. She notes Home Care Record days prior to that he is feverish and short of breath with congested cough. event RN contacts client’s family physician and transfer to hospital is arranged. Patient is admitted with community-acquired pneumonia. 5 days prior to Patient is discharged from hospital and returns to apartment. Hospital Chart and event INR testing during hospital stay resulted in Warfarin dose being Referral form reduced to 2 mg OD. Physician Referral lists medications Nifedipine 10 mg TID (calcium channel blocker), Atenolol 50 mg RN regularly BID (beta blocker), Coumadin 2 mg OD (anticoagulant), ASA 81 scheduled in the area mg OD (antiplatelet), Doxycycline 100mg OD x 6 days Interview (antibiotic), Nitrospray prn and DuoDERM® dressing to leg ulcer weekly and request to resume dressing change schedule as well as request for assistance with weekly bath. Referral received by fax on Saturday. RN responsible for that area of the community on the weekend does not know the client however she reviewed referral and home care record. Minimal changes noted so slotted for RN visit for dressing change in five days (Thursday) and Home Care Aide booked to make home visit for assistance with bath in six days (Friday). She leaves a voice mail for the regularly scheduled RN in the area to advise her of the client’s return home however that RN is off work for several days before receiving the message. She has significant backlog of messages and workload so does not take any action with this information. 5 days prior to Neighbour picked up Client to bring him home. She agreed to Client Interview event pick up the new prescription when getting groceries later that day. The pharmacist at the drug store gave a patient information sheet with the new prescription. The neighbour provided this to the Client. Date/Time History Client exhausted on the day he returned home from hospital. Grateful to neighbour for ride home and getting his prescription as well as groceries. He does recall the neighbour saying to read the information sheets but couldn’t find his glasses and was too tired. He noted the two “new pills” and daily dose directions. He added them to his medication regimen until the one pill bottle was empty.

Date/Time

Item

Comment/Source

5 days prior to event

At the drug store:  Pharmacy technician processes filling the prescription in computer.  Pharmacist notes the change in Warfarin/Coumadin dose from 3mg OD to 2mg OD so ensures that new bottle of tablets provided for ease of selfadministration. All medications are filled for dispensing to ensure that patient has sufficient supply for upcoming month.  Pharmacist attempts to explain dosing information to neighbour. Highlights the dose change on the patient information sheets as well as the potential of increased anticoagulant effect with the combination of Doxycycline and Warfarin. 4 days prior to Client continues to feel tired and not eating or drinking very event much. Spends much of the day resting in bed or watching TV. 2 days prior to Client indicates he felt weak and was also a bit concerned the event about the colour of his urine. He was also a bit embarrassed about seeing some blood on the toilet paper after he moved his bowels. He assumed it was his haemorrhoids giving him trouble again. 2 days prior to Client feeling weaker and more concerned about colour of the event urine and more blood in stool. Doesn’t want to bother neighbour so decides to wait until nurse visits in two days for dressing change. 1 day prior to Slept in bed most of day and doesn’t recall many other details. the event Day of event Client was found in bathroom by RN on arrival at 0900 for at 0900 hrs dressing change. Moderate amount of bright red blood in toilet and floor. Ambulance called and transferred to Emergency Dept. Day of event RN called ED and spoke with Charge Nurse. Patient’s INR 5.8. 1400 hrs Upon review of medication bottles it was determined that

Pharmacist interview

Client interview Client interview

Client interview

Client interview RN interview

RN interview

Date/Time

2 days after event

Item patient was unintentionally taking 5 mg of Warfarin daily as he did not know that Coumadin was the same medication as Warfarin so took previously ordered dose of 3mg and newly prescribed dose of 2 mg as well. Client remains in hospital but is recovering and should be ready to return home soon.

Comment/Source

Hospital chart

Additional Information: Picture of Warfarin/Coumadin 2 mg meds

Product monograph

Warfarin/Coumadin 3 mg