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Based on a review of 8 open and 4 closed medical records, review of policies, procedures, and interviews with staff and patients, it was revealed the hospital failed to ensure that patient #7 () received her correct dosage of Levothyroxine but instead received a dose ten times her usual dosage, and that increased inaccurate dosage was then conveyed to her community caregivers on discharge.

The hospital's Medical Reconciliation policy was reviewed and it stated in part under TX-35 revised 07/2012 :
"To the extent possible, providers and nurses will obtain a medication history from the patient and/or family member at the time of admission or encounter. The medication information will include, when possible, name, dose, route and frequency. The list of medications may be obtained from the following sources:
1.1.1.1 Patient ' s written medication list.
1.1.1.2 Patient or significant other ' s recall.
1.1.1.3 Patient ' s actual medication bottles.
1.1.1.4 Patient ' s pharmacy/pharmacies.
1.1.1.5 Patient ' s primary care physician list.
1.1.1.6 Patient ' s physician office. "
1.1.1.7 Patient ' s previous discharge paperwork."

Further policy information stated:

" 1.1.3 The admitting physician is responsible for comparing the medication history information with the patient's clinical status and inpatient medications to identify and resolve discrepancies (including, but not limited to: omissions, duplications, contraindications, unclear information, and changes). These changes are denoted on the Admission Medication Reconciliation Orders completed in the medication reconciliation computerized platform. "


Based on review of the medical records for patient#7 it was determined that Patient #7 was a 93-year-old female who presented to the hospital on 11/29/2014 with weakness in her left leg with an inability to walk. Patient #7 had begun to fall at her placement and was assisted to the ground. Patient #7 had a history inclusive of, but not limited to dementia, hypertension, hypothyroidism and glaucoma. Patient #7 was noted to be dehydrated on presentation. She was admitted to observation and was given fluids.

Patient #7 ' s medications included levothyroxine 25 mcg daily. A nurse who performed the initial medication reconciliation, incorrectly entered levothyroxine 250mcg daily. The History and Physical (H & P) that originated on 11/29/2014 at 2349 revealed in part, "For History of hypothyroidism continue Levoxyl 250 mcg daily. However, a physician addendum to the H & P on 12/1 at 2147 revealed " Her levothyroxine is 25 mcg daily. "

Review of Nurse Reports of 11/29/2014 at 2243 and 11/30/14 at 0029 reveals Levothyroxine sodium 100 mcg tab (Synthroid 100 mcg) PO/Daily" then "Levothyroxine 25 mcg tab (Synthroid 25 mcg) PO/Daily." Patient #7 ' s medication profile of 11/29 at 2353 stated "Levothyroxine tab 25 mcg PO/Daily @6. "

On 11/30 and 12/1/14, it was documented that Patient #7 received the correct dose of Levothyroxine 25 mcg at 6 am. A record entry for an order of Levothyroxine sodium 100 mcg tab Dose 250 mcg (2.5 tablets) was canceled on 11/29 at 2352. The cancellation comments states " Order clarified according to last admissions data and d/w (discussed with) MD."

However, while a discharge medication list stated " Levothyroxine Sodium 200 mcg daily oral 250 mcg daily oral - continue, " The Discharge Summary stated "Levothyroxine 25 mcg daily." While it is clear that the correct medication dosage was given during Patient #7' s admission, other records indicate that the incorrect dosage continued to appear in the hospital electronic medical record.

Patient #7 presented again on 12/29/2014 and was subsequently admitted on 12/30/2014 for weakness, cough and shortness of breath. Patient #7 had a hemoccult positive stool and was treated for anemia. Patient #7 was transfused with a pint of blood during her stay and received testing to determine the etiology of the occult stool.

A History and Physical revealed in part, "Levoxyl 250 mcg daily, " as did the nurse report where medications are documented for the initial medication reconciliation. On 12/30/2014 at 2231, a nurse documented Levothyroxine Sodium 125 mcg tab (synthroid 125 mcg) PO/Daily. Patient # 7 received a dose of Levothyroxine 250 mcg on 12/31/2014 at 1031, 1/1/2015 at 1042, and 1/2 at 1006.

The hospital Medication Reconciliation policy with regard to discharge stated " A computer generated form which provides the patient with a comprehensive list of their medication indicating those medications to be continued, those that require adjustments, and those medications which have been discontinued. The completed Medication Reconciliation/Discharge Form is a part of the medical record and is a valid Physicians Order. " A discharge medication list of 1/2/2015 revealed " Levothyroxine Sodium 250 mcg Daily Oral cont."

Patient #7 had been on telemetry monitoring which demonstrated a normal sinus rhythm throughout her stay with pulses in the 60-75 beat per minute range. Blood pressures remained relatively the same and were somewhat elevated on admission averaging 140-160 systolic over 60-75 diastolic.

Based on all documentation, it was revealed that an error in the medication reconciliation for Patient #7 resulted in the hospital failing to provide Patient#7 with safe medication dosing. Even after a physician correction during the first admission, the hospital failed to have safeguards in place which would have corrected the error throughout the patient medical record.