Advances in Patient Safety

ISMP Medication Error Cases and Prevention Checklist

October 9, 2009 | Lebowitz & Mzhen

In a prior post from this week concerning pharmacy error injury, our Maryland Medication Error Attorneys at Lebowitz & Mzhen Personal Injury Lawyers discussed a recent study published by the Institute of Medication Practices (ISMP), and the ongoing problem with drug naming standards in extended release medications.

In this study, the ISMP revealed a series of cases reported to the institute, in which drug name suffix medication mistakes have frequently occurred. This study showed specific case examples in order to establish clearer naming conventions in the industry, and improve comprehensive pharmacist and patient awareness—to prevent pharmacy error injury and misfills in the future.

The ISMP study reported these specific medication mistake cases:

• Physicians often prescribe extended release products without the correct suffix, or with a suffix that does not exist for that particular product.

• In an analysis of 402 prescribing errors published by Medscape Pharmacists, the most common type of error in the study (280 cases, 69.7%) was failure to specify the controlled release formulation.

• The ISMP received reports of cases in which pharmacists dispensed Metadate ER instead of Metadate CD—two different extended release forms of methylphenidate-UCB, a stimulant medicine commonly used to treat ADHD. In one case, a prescription for Metadate CD 20 mg was misfiled at a pharmacy, where the staff dispensed Metadate ER 20 mg.

• Some products have multiple suffixes for different formulations of the same drug. Diltiazem products for example (calcium channel blockers) are used to slow the heart rate and normalize the heart rhythm in hypertension and arrhythmia. The many suffixes for Diltiazem include SR, CD, XR, XT, and LA.

• Electronic prescribing can also lead to medication errors on behalf of the prescriber. In one case, a prescriber electronically selected metroprolol tartrate instead of metoprolol succinate because of choosing incorrectly on his PDA.

According to this report, pharmacists, practitioners, and patients should take extra care when reviewing the different formulations and medication names, especially if the medication is available in more than one dosage form.

The ISMP recommends the following medication error prevention checklist:

Government Program Hopes to Reduce Medication Mistakes Across the Country

April 27, 2009 | Lebowitz & Mzhen

In prior posts, Maryland medication mistake attorneys have asked our readers to question their doctors before taking prescription medications. Proactive patients are better able to notice potential medication mistakes before they occur and are less likely to suffer injuries.

The Agency for Healthcare Research and Quality (“AHRQ”), a part of the U.S. Department of Health & Human Services, has noted the substantial impact medication mistakes have on patients and the country as a whole. On itswebsite, the AHRQ quotes a report from the Institute of Medicine (“IOM”) which found that medication mistakes kill from 44,000 to 98,000 people each year. The report also indicated that medical mistakes cost the country approximately $17 billion each year in increased health care costs.

In order to help reduce medication mistakes, the AHRQ has developed a national ad campaign to encourage Americans to take a more active role in their health care by asking critical questions of their doctors, nurses, and pharmacists. The program drives home the point that Americans typically ask more questions of a cellular phone salesperson than they do of their physicians. The campaign’s website provides a top ten list of critical questions patients should ask their health care providers during appointments. Additionally, the website also has a “Question Builder” that allows readers to develop their own personalized list of questions.

New Technology: Handheld Device May Help Reduce Hospital Medication Errors

March 27, 2009 | Lebowitz & Mzhen

In a recent study, researchers found that improper dosages account for nearly 40% of medication errors. Additionally, researchers found that poor communication between health care professionals was the underlying cause of 15.8% of prescription errors. I read an article about an interesting piece of new technology that helps improve dose accuracy and communication between care providers.

The Intellidot Corporation has released the wireless IntelliDot Bedside Medication Administration (“IntelliDot BMA”) which will help eliminate hospital medication errors. The handheld device reads a barcode attached a patient’s wrist and provides the health care professional with all of the patient’s relevant health information. At an instant, a nurse or doctor will know all of the patient’s prescriptions, their required dosages, and the proper way to administer the medication. Additionally, in a hospital equipped with a computerized pharmacy, a doctor can electronically submit a prescription to the hospital’s pharmacy, and the pharmacy can transmit the prescription along with administration instructions to the IntelliDot BMA. Under this system, a hospital can eliminate the need for handwritten prescriptions and therefore greatly reduce the risk of errors caused by a physician’s poor handwriting or the use of improper medication abbreviations.

Universal Medication Form May Help Reduce the Risk of Injuries From Dangerous Prescription Interactions

March 24, 2009 | Lebowitz & Mzhen

In earlier posts, Maryland medication error attorneys at Lebowitz & Mzhen Personal Injury Lawyers have suggested that our readers always provide their health care providers with a full list of the prescription and over the counter medications they are currently taking.

The Institute of Safe Medication Practices (“ISMP”) has published a Universal Medication Form for patients to give to their doctors and pharmacists at each visit. On the form, a person can list their medication allergies, their immunizations, their current medications, the strength of their medications, and the frequency with which they take each prescription.

In order to avoid harmful drug interactions that can cause serious injuries or death, please take the time to accurately fill out this form or a similar one and bring it with them to all pharmacy, doctor, or hospital visits.

U.S. Army Uses Electronic Health Records To Help Reduce Medication Errors

March 20, 2009 | Lebowitz & Mzhen

The medication error attorneys at Lebowitz and Mzhen Personal Injury Lawyers are proud to have represented members of this country’s armed forces and their families in a variety of legal matters. In addition to the stresses that come with being a member of the military, soldiers and their families also have to be concerned about the risk of injury from medication errors.

The United States Army is comprised of 675,000 active duty soldiers. Army health centers are responsible for providing medical care to active duty personnel, their dependants, and a substantial population of veterans and their families. As a result, busy Army health facilities, including pharmacies, face the same risk of committing medication errors as their civilian counterparts.

The DeWitt Health Care Network serves 150,000 people in the Fort Belvoir Army community and is taking steps to reduce the risk of injuries from medication errors. Major Lela C. King, Chief of Pharmacy, reported that the network has given its patients pocket-sized medication cards that contain patient allergies, prescriptions, and other vital health information. These cards will reduce the risk of dangerous a physician prescribing a medication that interacts with one the patient is already taking.

Additionally, Major King has overseen the installation of digital patient records software and hardware in Dewitt facilities. According to Major King, the Army has recognized that such electronic health information can “decrease the number of medication errors made at the pharmacy by 70 percent.”

Side Effect Labels on Prescription Bottles May Help Reduce Injuries

March 18, 2009 | Lebowitz & Mzhen

The Food and Drug Administration is taking steps to warn consumers about potential drug side effects. The Maryland Pharmacists Association reports that sometime this year, the FDA will require all prescriptions to include a “side effects statement” that lists all of a drug’s potential side effects. The proposed labeling could appear on prescription containers and will advise patients to contact their health care provider and the FDA if they experience drug side effects.

Many of these side effects initially may be as minor as a runny nose or muscle stiffness. However, many of these insignificant annoyances can develop into more serious health concerns if a patient continues taking the prescription. To prevent more serious side effects, a patient should recognize any less serious side effects that might occur first and immediately contact their doctors. However, in order to take action, a patient has to know all of a drug’s potential side effects.

Listen to any radio or television commercial for the newest “wonder drug” and you’ll be shocked by the long list of potential side effects that the announcer speed reads before the commercial ends. Maryland medication error attorneys urge our readers to consult their physicians before taking medications so that they know a drug’s potential side effects.

MRI Scans and Drug Patches with Metal May Cause Burns

March 9, 2009 | Lebowitz & Mzhen

The medication error attorneys at Lebowitz & Mzhen Personal Injury Lawyers recently learned that the Food and Drug Administration has warned consumers who use medicated skin patches to remove those patches before going through a MRI scan. According to the FDA, some patches contain metal which may heat up during an MRI and burn the patient’s skin. The FDA warns that the metal in many of these patches may not be visible to the patient and not all transdermal patches that contain metal have patient warnings printed on the box. The FDA is currently reviewing the labeling requirements to ensure that patients are adequately warned of this new danger.

Until this review is complete, the FDA suggests that patients who use medicated patches do the following:

• Before undergoing an MRI scan, tell your doctor that you are using a patch and why you are using it;

Hospital Uses New Computer System to Reduce Pharmacy Errors

February 5, 2009 | Lebowitz & Mzhen

In earlier posts, the Maryland pharmacy error attorneys at Lebowitz & Mzhen Personal Injury Lawyers have discussed how computerized prescription entry programs decrease the risk of patient injury due to pharmacy errors. A study at the Norwalk Hospital in Norwalk, Connecticut is another example of how these systems work.

Recently, I spoke on the phone with a friend who lives in Norwalk and who is currently expecting her first child. As we talked about her child’s upcoming birth and the plans of her and her husband, she mentioned that the hospital where she is likely going to deliver her baby was in a local paper for being one of the safest in the nation. A recent newspaper article highlights how Norwalk Hospital in Norwalk, Connecticut employs a computerized prescription program that has, in part, helped earn nationwide recognition for patient safety. The computer system allows physicians at the hospital to electronically submit prescriptions with dosage instructions to the pharmacy, bypassing the necessity for doctors to write a hardcopy of the prescription. This procedures largely eliminates the possibility that the doctors’ handwriting will be misread.

Dr. Stephen O’Mahony, the associate chairman of medicine and a medical quality officer at Norwalk Hospital commented that, “With the old way we were doing things there was the chance of there being transcription errors, meaning a patient could get the wrong medication, but now there is no chance of [hospital pharmacists] reading it wrong.”

During the three years since the hospital introduced the computerized system, medication errors have decreased from an average of 13 errors per 1,000 patients to 2 errors per 1,000 patients. Additionally, the hospital has noticed a decrease in the length of hospital stays for Medicare recipients from an average of 7 days down to 5.7 days.

The electronic system not only prevents medication errors, it also uses a “best practices” approach to suggest the appropriate drug therapy for particular patients. For example, if a patient comes to the hospital suffering from a heart attack, the computer system will remind the doctor to prescribe aspirin. Also, when a doctor treats a person suffering from pneumonia, the system will prevent the doctor from discharging the patient until the patient has received a flu shot. With features such as these, the hospital’s computerized prescription program helps reduce the time patients suffer from their current aliments, and it also helps reduce the risk of further health problems.

External Links

Newspaper Article