Advances in Patient Safety

Major U.S. City Takes Steps to Reduce Pharmacy Errors

January 22, 2018 | Lebowitz & Mzhen

Maryland medical errors – including misfilled prescriptions – are one of the leading causes of death in the state and across the country. Indeed, a 2016 study by Johns Hopkins concluded that, if properly tracked, medical errors would be the third-leading cause of death in the United States. However, due to the fact that the law allows for voluntary reporting of most errors, many Maryland pharmacy errors go unreported.

According to a recent industry news report, Chicago is taking affirmative steps to combat the growing number of pharmacy errors. The city’s actions follow a report by a local paper indicating that of the 25 pharmacies surveyed, over 50% committed at least one error. The city’s attempts are premised on the longstanding and verified belief that the more prescriptions a pharmacist fills per shift, the higher is the chance that the pharmacist will make a medication error in the type, dose, or administration of a drug.

In an attempt to reduce future errors, Chicago lawmakers have proposed a number of pharmacy regulations. For example, one proposed regulation limits the total number of prescriptions a pharmacist can fill by hour to 10. Another regulation requires that pharmacists who have been working in excess of eight hours notify patients as they fill their prescription. Lawmakers have also proposed that pharmacists be required to take one 30-minute lunch break and several 15-minute breaks per eight-hour shift.

Experts Hope a Bottle’s Label Design Can Decrease Prescription Errors

January 2, 2018 | Lebowitz & Mzhen

Prescription medications are controlled by the government for good reason. Indeed, many prescription drugs are dangerous substances that are only approved for use under strict conditions for very specific applications. It may be that a prescription drug negatively interacts with other commonly consumed medications, or that the medication itself easily leads to dependency and addiction. The bottom line is that prescription medication can be dangerous, and pharmacists and manufacturers should take all steps necessary to prevent Maryland pharmacy errors.

One of the most important tools pharmacists can use to decrease the chance of a serious or fatal prescription error is to make sure that the label affixed to the prescription is correct and written in plain English so that the patient can understand the directions. According to a recent news report, experts have been studying the impact that label design has on a patient’s likelihood of experiencing an error. The study found that patients are experiencing errors even with properly filled medications due to confusing medication labels.

For example, the article discusses a situation in which a woman was prescribed a patch containing pain medication to help with her arthritis. The label indicated the woman should apply the patch when she feels pain, but it did not specify how many patches to use at one time. The woman’s family later discovered that she had been using the pain patches all over her body, effectively overdosing on the medication contained in the patch.

As Online Retailer Enters Pharmaceutical Business, Some Are Advocating for Change

December 1, 2017 | Lebowitz & Mzhen

The online retail giant Amazon recently announced that it would soon be entering the pharmacy business. With Amazon’s impressive delivery network, the company believes that it has a service to offer those who would otherwise need to travel to the nearest pharmacy to fill their prescription. Some believe that Amazon’s entrance into the pharmacy business may reduce the number of Maryland prescription errors.

Due to the volume of transactions that Amazon handles annually, some are seeing Amazon’s entrance into the pharmacy business as an opportunity for the industry to make major strides toward a safer process. The idea is that Amazon has the clout necessary to make pharmaceutical companies make changes to the way drugs are packaged and marketed.

According to a recent industry news report, the leading cause of pharmacy errors is inadvertence. Simply stated, most pharmacy errors are results of a busy pharmacist grabbing the wrong medication because its name or packaging is so similar to the medication the patient requires. And, according to the article, drug manufacturers have little reason to change because they are not normally held liable for errors. However, the article notes that as Amazon enters the business, the company may be able to use its influence to require manufacturers to make changes to the way companies package and market their drugs, potentially resulting in an overall decrease in the amount of pharmacy errors.

Experts Push to Decrease Prescription Errors by Changing Labeling and Packaging

November 8, 2017 | Lebowitz & Mzhen

Prescription errors can have devastating consequences for Maryland patients. These types of errors can be caused by a number of different issues, including writing the wrong prescription and dispensing the wrong medication. Some of these errors may be reduced by changing something as simple as the packaging of the medication. Some drugs have similar names, and other bottles look alike, increasing the likelihood of error. Experts are pushing companies to make changes in cases of confusing labeling, naming, and packaging.

In a prescription error case, an individual must show that the defendant was negligent in doing or failing to do something by failing to meet the standard of care required. This might include failing to properly read the label on a medication bottle. However, industry experts are working to help medical professionals avoid such errors.

FDA Guidance Seeks to Reduce Errors Due to Labeling and Packaging

Look-alike and sound-alike medications increase the likelihood of prescription errors, according to one news source. One report found that 33 percent of all medication errors and 30 percent of deaths from medication errors resulted from issues with medication labeling and packaging.

Five Ways Pharmacists Can Help Prevent Pharmacy Errors

September 22, 2017 | Lebowitz & Mzhen

Tens of thousands of patients are provided the wrong medication, wrong dose, or wrong instructions in their prescriptions each year. These Maryland pharmacy errors can range in seriousness. On one end of the spectrum are the errors that are caught by the patient before any medication is ingested. While these errors present no risk of injury, they are still alarming.

More serious prescription errors are those that result in serious injuries or death. While there are tens of thousands of documented errors each year, approximately 7,000 of these errors are fatal. Over the past decade, the pharmacy industry has been the focus of many studies looking at how to decrease the cases of serious and fatal errors. A recent report discusses five of the most common recommendations for pharmacists to take that will decrease their error rates.

Provide enough pharmacists – One of the leading causes of pharmacy errors is that the pharmacist filling the prescription is overworked. By ensuring that there are enough pharmacist staff members on duty, pharmacies are able to keep workloads manageable and provide much-needed breaks to pharmacists.

Automated Prescription Dispensing Systems Still Capable of Making Errors

August 22, 2017 | Lebowitz & Mzhen

With the increase of pharmacy errors over the past several years, many pharmacies are looking to automated systems to reduce the element of human error in the filling of prescriptions. Indeed, most Maryland prescription errors are caused by busy pharmacists trying to keep up with what seems like a never-ending workload. While pharmacists are certainly well-intentioned, the reality is that by acting in haste, they place patients at risk.

In many cases, these automated systems use a series of bar codes to inventory, track, and dispense medication, making sure that the proper medication gets to the patient. However, even with the advent of these new automated systems, serious pharmacy errors still occur. When a pharmacy error does occur, the results may be devastating, especially when the patient is elderly or young, or when the medication in question carries serious side effects.

Infant’s Mother Provided Expired Medication at Retail Pharmacy

Earlier this month, the mother of a four-month-old baby was given medication for her child that had been expired for six months. According to a local news report covering the error, the child was suffering from a severe case of acid reflux and was prescribed medication for the condition by the family’s physician. The mother took the prescription to a local pharmacy, picking up four boxes of the medication. By the time the mother got back to her car, she double-checked the box and noticed that all four boxes had been expired for six months – two months before her baby was even born.

Pharmacy Error Rates May Be Artificially Low Due to a Lack of Mandatory Reporting Requirements

June 29, 2017 | Lebowitz & Mzhen

Chances are anyone who has followed the news over the past few months has noticed at least one serious pharmacy error occurring at either a hospital or a retail pharmacy. Indeed, the Food and Drug Administration estimates that there is on average one death per day in addition to approximately 1.3 million people harmed per year by pharmacy errors. However, these statistics are only estimates because the real number of errors cannot be determined, due to discretionary reporting requirements.

As the law stands now, pharmacies are not required to report most of the errors that their pharmacists make. While some errors come to the public’s attention due to widespread press coverage or because a pharmacy error victim files a personal injury lawsuit, many errors go unreported. Thus, the true number of pharmacy errors is unknown.

According to a recent article, our neighbors to the north in Ontario, Canada have begun to implement mandatory reporting requirements. Evidently, the change in the law was spurred on by the death of an eight-year-old boy last year. The report indicates that the boy suffered from sleeping problems and was prescribed tryptophan by his pediatrician. The boy’s mother called in the prescription and went to pick up what she thought was tryptophan, but what she was given was actually baclofen, a powerful muscle relaxer. After the boy’s death, the coroner reported that “logic would dictate that baclofen was substituted for tryptophan at the compounding pharmacy in error.”

The Lack of Mandatory Reporting Requirements in U.S. Pharmacies

April 3, 2017 | Lebowitz & Mzhen

In most professions, when someone makes a serious error that affects the health or safety of another person, it becomes public knowledge. Indeed, we often read in the news about reports of doctors, police officers, and politicians who make questionable judgment calls. The fact that these lapses in judgment become public knowledge allows for the public to better understand the errors and encourages brainstorming about how to reduce those errors in the future through better policy-making and enforcement.

Pharmacists, however, do not face mandatory reporting requirements in much of the country. In fact, in most states, pharmacists are given discretion about when to report most errors. Interestingly, Maryland is ahead of the curve in requiring that certain adverse patient-related events, including medication errors, be reported within five days by medical professionals, including pharmacists.

The Seriousness of Pharmacy Errors

The Food and Drug Administration estimates that medication errors cause more than one death a day and injure over 1.3 million people annually. While not every prescription error will result in a serious injury or death, it is important to realize that the effects of a pharmacy error may not be immediately apparent. In some cases, medical experts are required to establish which, if any, consequences a patient who has been provided the wrong medication may face in the future.

Despite the High Prevalence of Pharmacy Errors, Pharmacists Resist Lawmakers’ Attempt to Impose Stricter Guidelines

March 13, 2017 | Lebowitz & Mzhen

By any account, pharmacists do not have an easy job. They often fill hundreds of prescriptions per shift, meet with dozens of clients for consultations, and must also maintain their internal inventory systems throughout the day. Pharmacists are human, and with these burdens being placed upon them day after day, it is no surprise that the rate of pharmacy errors is as high as it is.

According to one news report that discussed a study it conducted of Chicago-area pharmacies, 52% of all pharmacies surveyed failed to warn patients about a dangerous drug interaction. This study didn’t take into account other types of pharmacy errors, such as providing the patient with the wrong dose of medication or the wrong type of medication altogether. The news agency looked mostly at both independent and national-chain pharmacies, discovering that CVS had a failure rate of 62%, Walgreen’s had a failure rate of 30%, and independent pharmacies had a failure rate of 72%.

Due to the concerns surrounding pharmacy errors, lawmakers have recently started to try to implement stricter guidelines for pharmacists. The proposed changes would limit a pharmacist’s workday to 8 hours, require pharmacists take two 15 minute breaks and an hour lunch, and limit the number of prescriptions filled per hour and per shift. Despite the undeniably high error rates, some pharmacies and pharmacists have opposed the newly proposed laws.

Some Pharmacy Errors Caused by Small Print on Medication Bottles and Other Medical Literature

November 29, 2016 | Lebowitz & Mzhen

A recently published medical industry report attempts to point out the surprising threat that American patients face every day in doctor’s offices and hospitals due to the small print that is used on many prescription forms, medication bottles, and medical review materials. The report, which was supplied to the publisher by a company seeking to profit from the present-day problem, notes that a survey of health care professionals performed in 2014-2015 found that almost 90% of doctors, nurses, and other health care professionals reported difficulty reading the small print found on drug labels and that over 35% were aware of a close call or actual prescription error that occurred because of the small print on some medical materials.

Doctors Who Don’t Need Reading Glasses or Assistance From a Colleague with Adequate Vision May Make Mistakes and then Blame the Small Print

The report contains startling information that millions of patients may be placed at risk every day because doctors and nurses are unable to read medication bottles correctly, and some of these professionals apparently do not take the initiative to ensure that their eyes are functioning well enough to protect their patients from a pharmacy or medical error stemming from a piece of medical literature that is read incorrectly. The article seems to place the blame for these errors and any injuries, illnesses, or deaths they cause upon the small print that is used on medication bottles. However, the bottom line is that medical professionals are responsible for reading what is on medication bottles and other literature before they give a potentially dangerous medication to a patient.

If a medical professional is unable to read a piece of text and does not seek assistance by consulting a colleague, putting on some glasses, using an app on their smartphone, or using a piece of magnification equipment to ensure that they understand what they are doing, they should be held responsible for any injuries that are caused by their mistake.