£50,000 Fine for Fatal Drug Errors. Time to Update Your Medication Practices?

A care home owner and its former manager were fined a total of over £50,000 as a result of a failure to provide safe care. The provider, Coverage Care Services Ltd, was fined £50,000 and the former manager received a fine of £665 as a result of a CQC prosecution following an investigation into the death of a service user.

Following the death, the case was referred to the coroner as a result of concerns about errors in the administration of anticoagulant medication and the post mortem revealed the cause of death to be a pulmonary embolism and deep vein thrombosis.

The investigation revealed a number of omissions and errors including the dose and duration of the anticoagulant drug being inaccurately recorded and a failure to obtain further stock when supplies ran out, leading to the anticoagulants not being given for 30 days prior to the resident’s death.

The investigation found that although the death could not be directly linked to the medication errors, residents living at the home had been put at risk of significant harm because of the home’s management and recording of medicines.

Thankfully, such extreme cases are relatively rare but this incident highlights the disastrous consequences that can occur as a result of poor practice in medication management. Read on to learn the essential steps you should always take when administering anticoagulant drugs to people in your care and protect your service users from avoidable harm.

The most frequently used oral anticoagulant in the UK is Warfarin, a well-known and well-established treatment. Warfarin is frequently prescribed for people who have had a stroke, heart attack or deep vein thrombosis and can be used to treat a range of other clotting-related conditions. However, if not taken correctly, it can lead to serious side effects including death.

5 Steps to Safe Anticoagulant Practice

  1. Maintain a consistent dose and time: Warfarin tablets should be taken at the same time each day with a full glass of water. If a dose is missed, a note should be made on the MAR chart. Continue the next day with the normal dose – do not give an extra dose to ‘catch up’.
  2. Know the colour scheme: Ensure your staff administering medicines are familiar with the different colours of the various strengths of warfarin tablets as this will help to reduce the risk of a wrong dose being given.
  3. Double check: Always double check the information on the MAR chart against the person’s individual warfarin dosage book or card. The most up-to-date information based on the most recent INR (international normalized ratio) result should always be used and it is good practice to attach the written oral anticoagulant dosage supplied for the person onto the MAR chart.
  4. Regular blood testing: The GPs should always check that the person’s INR is at a safe level before issuing a prescription for warfarin. There should be a clear process for ensuring blood tests are taken at the correct time, that INR results are received and that the correct dose is transcribed on to the MAR chart.
  5. Obtain results promptly: You should have in place a process to follow up INR results and warfarin dosage if they have not been received within 3 days. Ensure the telephone number for contacting the anticoagulation service is recorded on the person’s notes and MAR chart for easy reference.

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