LEGAL ISSUES| Volume 18, ISSUE 11, P12, November 01, 2017

# An Avoidable Mistake and a Wake-Up Call

Jane Doe was a frail 81-year-old female resident who had resided in a skilled nursing facility for 18 months. Her medical history included hypothyroidism from having had a total thyroidectomy when she was a young adult. She required levothyroxine daily.
After Ms. Doe had been a resident at the SNF for approximately 15 months, she was transferred to the hospital, then discharged to the SNF 3 days later. There had been no changes to her levothyroxine order. But when Ms. Doe was readmitted to the SNF, the licensed vocational nurse (LVN) who transcribed the transfer orders from the hospital failed to transcribe the levothyroxine order. The facility had no policy in place to compare the orders on a readmitted patient to the medication administration record (MAR) from the previous admission.
The admitting LVN recalled verifying the admitting orders with the nurse practitioner. After drafting the physician’s orders, it was her practice to fax the orders to the pharmacy to obtain the medications. Initial MARs were then created based on these transcribed physician’s orders, and were not based on the orders actually received from the hospital.
During her long residency, Ms. Doe was seen at regular intervals by her attending physician, his nurse practitioner, and another physician in his group. None of these clinicians caught the transcription mistake, and none of them realized that Ms. Doe was no longer receiving her levothyroxine. As the days went on, Ms. Doe was receiving all her other chronic medications, but none of the facility staff realized that she was not receiving her levothyroxine. The consultant pharmacist reviewed the file twice after her readmission and also failed to catch the omitted levothyroxine.
Ms. Doe gradually began exhibiting signs of hypothyroidism, but none of the health care practitioners made the connection between her symptoms and her failure to receive levothyroxine.
Ms. Doe did not receive levothyroxine for 3 months. She was transferred to the hospital with hypotension and mumbled speech. The hospital determined that she had not been receiving her levothyroxine, and it was resumed. However, her laboratory work demonstrated extremely high levels of thyroid-stimulating hormone (TSH) and a negligible amount of circulating thyroid hormone (T3 or T4). She developed respiratory failure and pneumonia, and she could not be weaned from the ventilator. Ms. Doe’s family decided to withdraw ventilator support due to her poor prognosis, and Ms. Doe died 25 days after being admitted to the hospital. The death certificate listed hypothyroidism as a contributing cause of her cardiopulmonary arrest.

## Best Practices

Transcription is a source of many medication errors. Contributing factors include incomplete or illegible prescriber orders, incomplete or illegible nurse handwriting, use of abbreviations, and lack of familiarity with drug names. Omission is a particularly dangerous medication error and generally results from being rushed and/or being interrupted during the transcription process. To avoid such errors,
• Complete the transcription process in a quiet, well-lit area, away from distractions. If you are transcribing orders in a busy environment, there is a higher likelihood that you may make an error.
• Implement a system to check the medication administration record document against active orders, whether the MAR is manually documented or computer generated.
• Implement a second check system for the transcription.
• If the patient is a readmit, compare the proposed current medications to the MAR from the prior residency to ensure daily, required medications are being continued or any long-standing medications are discontinued if there is a valid reason.
• Call the prescriber if any discrepancies are found and clarify the continuation or discontinuation of hospital medications.
• Have pharmacists review the list of medications prescribed for patients being transferred to the SNF. Pharmacists can help identify omitted or non-indicated medications and dosing errors.
Ms. Doe’s death related to the failure to provide levothyroxine was eminently preventable. Her death served as a wake-up call to facility staff and management about the importance of taking just a few extra minutes during the transfer process to ensure resident safety. Had the LVN not been interrupted or had taken the time to compare her orders with Ms. Doe’s previous MAR, the order may not have been omitted. In this instance, those few minutes were the difference between life and death.
This column is not to be substituted for legal advice. Mr. Wilson is a partner in the law firm Wilson Getty LLP, which represents all types of long-term care facilities against civil claims.