When a patient was accidentally prescribed three anticoagulation medications, the consequences could have been life-threatening. She was horrified to learn what had happened, and it shook her trust in hospitals. “If this could happen, what else could go wrong?” she asked.

In this case, the care team had tried to ensure the safest possible care for her multiple medical needs. Then, due to her concern about cost, they attempted to check the price of a medication before prescribing it, unaware that this would ultimately cause the error that led to a dangerous combination of prescriptions.

“I felt terrible,” the attending physician said. “Our intern went above and beyond to create a very safe discharge plan for this patient, including finding her a new primary care physician and communicating all of the information about her treatment and medications to the PCP. When we heard about the mistake, we felt like we had really let her down.”

Sometimes, providers feel like they are set up to fail when it comes to patient safety. In an increasingly complex environment, simply telling clinicians to be more careful cannot be our sole safety strategy– we need reliable systems that are resilient to human error.

We were fortunate to get the perspective of the patient in this case, and I encourage you to read about how it affected her and the words of wisdom she has for health care providers.

Thanks for reading,

 

 

 

What Happened

When a patient who was admitted with a blood clot in her lungs was ready to be discharged, her care team discussed the risks and benefits of two different anticoagulation regimen options with her—(1) warfarin (an oral anticoagulant that is commonly prescribed to treat blood clots that requires close laboratory monitoring and therefore multiple blood tests) with an enoxaparin “bridge” (an injectable anticoagulant that is needed for the short term until the warfarin takes full effect) or (2) rivaroxaban (a newer type of oral anticoagulant that requires far less blood draws for monitoring when compared to warfarin).  During the discussion, the patient mentioned that medication cost would be a consideration.

There are no simple ways to check the price of a medication because prices vary with different types of insurance. Sometimes the prescription just needs to be filled to determine the price.  In this case, the intern sent the prescription for rivaroxaban electronically to the patient’s pharmacy and followed up with a phone call. The rivaroxaban turned out to be too expensive, so the team prescribed a combination of warfarin and enoxaparin and discussed the plan with the patient.

Several days after discharge, she had a blood test that showed she had exceeded her anticoagulation targets and was at risk for bleeding. This triggered a call from the BWH anticoagulation pharmacist. After reviewing her dosing and medications, the pharmacist realized she was taking not only the warfarin and enoxaparin as planned, but also the rivaroxaban —a dangerous combination.

What Went Wrong

The error in prescribing the medications was caused because of the need for a price check of the medication prior to her discharge. Upon learning that the rivaroxaban was too expensive, the intern discontinued it in the patient’s electronic medical record, but did not realize that the discontinue order was not transmitted to the pharmacy.  When the patient went to the pharmacy, all three medications had “active” prescriptions and were filled.  The pharmacy also did not catch that this combination of medications was dangerous and gave them to the patient without alerting anyone to the potential dangers.

Fortunately, her medications were clarified quickly, and she suffered no ill effects.

What We Did

Here’s how we are working to prevent this type of error in the future:

• Disclose and apologize: The attending physician called the patient to tell her about the error and apologize.
• Improve the system: The error happened just before BWH’s comprehensive electronic health record, was implemented. Now, with our new electronic health record, an alert pops up to remind the provider to call the pharmacy and cancel a prescription if the medication is discontinued in the medical record.
• Increase pricing information availability: We are looking into better ways to check medication prices without having to send a prescription to the pharmacy.

In addition to the above, a Patient Safety leader at BWH spoke to the pharmacy where the patient filled her prescriptions to share what happened and discuss opportunities for quality improvement. She also helped to facilitate the patient’s reimbursement for the rivaroxaban.

From the Patient’s Perspective

The patient first realized something was wrong after her blood test when the pharmacist from the anticoagulation management service called her. “He asked me to review my medications with him,” she recalls. “I read him the labels of the first two medications, and he was quite confused because I wasn’t doing anything wrong. I said, ‘Don’t you want me to read the third one?’”

Stunned to hear that there was a third medication, the pharmacist asked where she got the rivaroxaban. “I told him that I picked up my drugs, and there it was,” she said.

The pharmacist told the patient to stop taking her medications immediately and wait until he called her back with instructions.

“He said I could faint or start bleeding internally,” the patient said. “It was horrifying. I would have no help here. I’m home alone and no one would even know.”

She heard back from the pharmacist right away, and her physician also called.

“My doctor is wonderful. We had a big long talk about everything,” she said. “He was very sympathetic and apologized. He called me more than once and even gave me his personal number if I ever needed to reach him.”

The patient also had helpful suggestions for preventing this kind of mistake from occurring again: not only should there be an alert for the physician and the pharmacy, but there should also be education for the patient. “When you’re a patient, you’re so sick and worried that you don’t ask a lot of questions,” she said. “You assume the doctors and nurses know what they’re doing. But we’re all human. Someone on the care team should answer the questions the patient doesn’t know to ask when they’re being prescribed a new medication.”

The patient describes it as an eye-opening experience. “Ever since then, I’m horrified with all these medications. I’m a person who never wanted to take anything anyway,” she said. “And if something like this could go wrong, what else could go wrong?”

In sharing her story with Safety Matters, she said she was pleased to know that BWH was working to prevent this kind of error from happening to someone else. “I’m grateful everything turned out all right for me,” she said.