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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 4/1/2020 12:00:00 AM
Country: Hong Kong
This alert describes a serious adverse medication incident as a result of a missed dose. A patient with paroxysmal atrial fibrillation on apixaban (non-formulary, home medication) twice daily was admitted for dizziness. Noting the family member would bring apixaban back from home, 'Omit' was marked at the Inpatient Medication Order Entry (IPMOE) record with the reason ‘Drug was not available’ during the medication round at night. The night dose was thus omitted. There was an assumption that the family would bring the drug back that evening. The family only brought the medication back next morning. The patient developed left-sided weakness in the afternoon. Computed tomography of brain showed cerebral infarct. The alert provides a recommendation to prevent similar incidents focusing on the difference between “omit” and “defer” for entry in the Inpatient Medication Order Entry (IPMOE) record.

Additional Details

Medication/Gas/Fluid:
apixaban (Eliquis)
Medication/IV List:
antithrombotic agents (anticoagulants), including warfarin, low-molecular-weight heparin, IV unfractionated heparin, Factor Xa inhibitors (fondaparinux), direct thrombin inhibitors (e.g., argatroban, lepirudin, bivalirudin), thrombolytics (e.g., alteplase, reteplase, tenecteplase), and glycoprotein IIb/IIIa inhibitors (e.g., eptifibatide)

Rules / Policies / Procedures
  1. There are differences between ‘Omit’ and ‘Defer’ in IPMOE: Omit -- Use this when the dose will not be given. Drug administration process is completed. Defer --Use this when the dose is to be given later.

Medication Error One Dose of Apixaban Omitted