Advances in Patient Safety

CVS Pharmacy Error Leads to Amoxicillin Overdose in Child

May 6, 2011 | Lebowitz & Mzhen

In our last Washington D.C. pharmacy error injury lawyer blog, our attorneys discussed the dangerous problem of pharmacy misfills with children, and how important it is for parents to check prescriptions before leaving the pharmacy to make sure that their child has the right medication.

Other important information for parents to double check with the doctor and pharmacist is the child’s medication dosage and instructions, as a single error could lead to improper medication dosing, and possible injury.

In recent pharmacy mistake news in North Carolina, a 9-year-old child was prescribed the antibiotic amoxicillin for an ear infection. The doctor had prescribed 7 milliliters twice a day, but the CVS pharmacist who filled the prescription reportedly instructed Melissa Fink to give her daughter 7.5 teaspoons—which amounts 37 milliliters–or 5 times the recommended dosage of the doctor.

When Fink’s daughter became worse, and the bottle was nearly empty only two days of giving her the medicine, Fink’s doctor realized the medication error, and advised her to bring her child in immediately. Thankfully the antibiotic overdose did not cause major harm or injury, but according to the Carolinas Poison Center, amoxicillin overdoses can be serious and lead to dehydration or kidney failure.

Children’s Hospitals Form Collective Effort on Patient Safety to Prevent Medication Errors

April 13, 2011 | Lebowitz & Mzhen

According to a recent article in Pharmacy Practice News that our Washington D.C. pharmacy error injury attorneys have been following, a group of children’s hospitals in Ohio have prevented around 3,600 adverse drug events and surgical site infections, along with saving over $5 million, during an 18-month program initiative that was launched in 2009.

The initiative, called “Solutions for Patient Safety,” was reportedly launched with support of the Cardinal Health Foundation, who gave 1.5 million, along with the shared motivation of children’s hospitals in an effort to work together to eliminate preventable injury or harm to children.

Before the initiative began, each children’s hospital in the state reportedly collected data on adverse drug events in a different way—making it very difficult to compare or share information within hospitals. After conducting audits of a random collection of charts, the group was able to come together and manually identify and review the root cause of adverse events, and pinpoint a set of common concerns.

The initiative found that the main collective medication error problem was constipation from opioids, as well as over sedation as a result of the narcotics. Although constipation is not a life-threatening adverse drug event, it can reportedly add to more time in the hospital, more lab work, and tests, which can all add to additional costs.

Benefits of Robo Pharmacy Technology in Reducing Prescription Errors

April 1, 2011 | Lebowitz & Mzhen

In a recent Maryland pharmacy error injury lawyer blog entry, our attorneys discussed automated hospital pharmacies the use robots instead of people for tasks that are traditionally manual—in an effort to eliminate medication errors that could cause patient harm or personal injury.

According to the Medical Center of the University of California, San Francisco (UCSF), a hospital that recently implemented an automated hospital pharmacy–the benefits of using an robots instead of people are:

• Robots will help take over the manual medication dispensing tasks traditionally performed by pharmacists and nurses, who will in turn have more time to work with physicians to decide what the best patient drug therapy is, and will have more time to monitor each patient for any clinical responses or adverse reactions to medicine.
• The new pharmacy will provide pharmacy students with a strong training ground in the safe medication distribution systems of the future.
• The pharmacy will also enable the center to study new forms of medication delivery in order to share this groundbreaking information with other hospitals all over the country.

• Out of the 350,000 doses prepared by the robo-pharmacy since 2010, there has not been a single medication error or pharmacy misfill.

According to UCSF, the automated medication dispensing system will allow pharmacists to use their expertise in pharmaceutical care to make sure that each patients receives medication therapy that is catered to their individual needs, in a safe and effective way.

UCSF Employs New Automated Pharmacy to Prevent Pharmacy Error

March 28, 2011 | Lebowitz & Mzhen

In an effort to reduce pharmacy misfills and medication error, the Medical Center of the University of California, San Francisco (UCSF), has recently employed a series of pharmacy robots, according to recent technology news that our Baltimore-based pharmacy misfill attorneys have been following.

In the newly automated hospital pharmacy, UCSF has employed what they consider to be the most comprehensive robots on the market, to prepare and track medications and improve the safety of patients. According to UCSF, since the automated system took over in October 2010, there has not been a single error in the 350,000 medication doses prepared.

This newly automated pharmacy reportedly streamlines the delivery of medication from the prescription directly to the patient, making every step in the medication therapy process safe and effective–from deciding the best drug treatment to patient administration—in order to reduce medication error injury.

How the Robo-Pharmacy Technology works:

• The automated system reportedly prepares medications that are oral and injectable, including chemotherapy drugs that are toxic. The robots are also able to fill IV bags or syringes with medications.
• Once the computers receive a new electronic medication order from an UCSF physician and pharmacist, the robots pick the medication, package the drugs, and dispense doses of the pills that are individualized for each patient.
• The robots assemble medication doses into a thin plastic ring that contains a bar code with all of patients’ medications for a period of 12 hours.
• In the fall of this year, all UCSF Medical Center nurses will start using bar code scanners that read patients’ medication data at their bedsides–a topic our attorneys have discussed in a recent Maryland pharmacy error injury blog–to verify that the patient is being treated with the correct medication.
• A robotic inventory management system also maintains all medication products, with pharmacy warehouses that provide both refrigerated and non-refrigerated drug and supply storage and retrieval.

Study Finds Small Doses of Drugs From Syringes Could Cause Medication Error in Children

February 4, 2011 | Lebowitz & Mzhen

As our Baltimore County pharmacy error attorneys discussed in a recent blog, according to a recent study by the Agency for Healthcare Research and Quality (AHRQ), medical errors are a leading cause of personal injury and death in this country, and rates for possible adverse drug events were three times higher with children than adults in hospitals, with an even higher rate for infants in intensive care units.

In a new study, published in the Canadian Medical Association Journal, a report found that preparing small medication dosages from syringes for infants and children can be dangerously inaccurate and cause medication dosing errors.

According to the report, in administering potent drugs to young patients, small doses are often prepared from medication stock of less than 0.1 milliliter (mL) in size, but the current equipment used to administer the drug does not allow for the correct and accurate measuring of drug volumes that are less than 0.1 mL.

Dr. Christopher Parshuram, the author of the study, who works in the University of Toronto’s Department of Pediatrics and directs the University of Toronto Center for Patient Safety’s Pediatric Patient Safety Research, stated that medications regularly requiring small doses include narcotics and sedatives that are extremely powerful, such as morphine and fentanyl—both drugs that as our Maryland medication error attorneys have reported in a recent blog, have a high-risk for medication mistakes which could lead to patient injury or wrongful death.

FDA Reports on Fatal Morphine Oral Solution Medication Errors

January 26, 2011 | Lebowitz & Mzhen

According to a recent report from the U.S. Food and Drug Administration (FDA) that our Washington D.C. medication error lawyers have been following, a morphine solution that was approved by the administration last year, has been linked to a series of morphine overdoses and deaths due to medication error—leading federal regulators to issue a warning and initiate a label change to prevent personal injury or death.

The FDA’s recent notification to the health care industry and consumers reported on the overdoses and deaths that have occurred as a result of morphine sulfate oral solution medication errors, most of which are linked to the high potency (100 mg per 5mL) product, where solutions ordered in milligrams (mg) were erroneously mistaken for milliliters (mL) of the drug, causing fatal overdoses.

When milligrams (mg) are misread and confused for milliliters (mL), the patient dosage could reportedly be as high as 20 times stronger than the dosage intended for the patient, which could result in a drug overdose. Other medication mistakes were reportedly caused by confusion in medication dosage, and understanding the morphine concentration in the oral solution.

As our medication mistake attorneys in Baltimore, Maryland have reported in a related blog, according to the Institute of Medicine’s (IOM), 1.5 million people are injured by preventable medication errors every year, with 98,000 annual deaths from medical errors—7,000 of which are due to medication mistakes.

The morphine sulfate oral solution is manufactured by Roxane Laboratories, Inc., and is used to tread moderate to severe chronic and acute pain with patients who are opioid-tolerant. In a blog from this week, our attorneys discussed the danger associated with an incorrect administration of a powerful prescription pain medication and the prevalence of fatal medication overdoses with patients who are opioid-intolerant and are erroneously prescribed these medications.

Pharmacy, Nursing Home Sued After Pharmacy Misfill Leads to Resident’s Death

January 7, 2011 | Lebowitz & Mzhen

In recent news that our Washington D.C. pharmacy error attorneys have been following, a nursing home was fined $12,000 last month, after a pharmacy misfill caused a nursing home resident to receive the incorrect medication for 18 days, leading to her wrongful death.

The Auburn Citizen reports that according to an investigation by the New York State Health Department in March and April of 2009, Geraldine Burke, a 94-year-old resident, was given tablets of a blood pressure medicine and diuretic by three different nurses in the Cayuga County Nursing Home, instead of the thyroid medication she had been prescribed.

The tragic medication error reportedly happened as a result of a pharmacy misfill, where a technician at HealthDirect, a separate division of Kinney Drugs that provides pharmacy services for more than 100 facilities, had filled and shipped the wrong medication for Burke. The two medications reportedly had similar looking names—methimazole and metolazone—a common medication mistake that plagues pharmacies in this country, as our lawyers have reported in a recent blog.

Neither the pharmacy or the nursing home recognized the mistake, and Burke was given 11 doses of Metolazone, the diuretic. The autopsy reportedly found that Burke died from heart issues, that were a result of kidney failure, worsened by the diuretic, along with other conditions. When the facility discovered the medication error after her death, they reported it to the Health Department, where they were fined $12,000. Burke’s family sued Cayuga County for negligence, and in turn Cayuga sued HealthDirect for their pharmacy misfill.

A Pharmacy’s Guide to Medication Therapy Management

January 6, 2011 | Lebowitz & Mzhen

In a recent blog, our pharmacy misfill error injury attorneys in Baltimore, Maryland discussed the importance of medication therapy management (MTM) check-ups with a pharmacist, to avoid medication error, pharmacy misfill, and potentially dangerous drug mix-ups that can lead to patient injury or even wrongful death.

The goal of an MTM is to get the maximum benefit from a patient’s prescription medication, and to have the opportunity to ask the pharmacist questions, as one would talk with their doctor, to avoid any medication error, possible side effects or problems with single or multiple medications.

People who reportedly benefit from consulting a pharmacist about medication management are:

• Patients taking medication for more than one chronic condition such as diabetes, depression, asthma, or high blood pressure.
• Patients who are taking one drug with potentially risky side effects, such as the blood thinner warfarin, or medication for seizures.

• Patients who have a hard time following a medication schedule, who forget to take their medicine, or skip them because they are experiencing side effects.

When attending an MTM, Family members or care givers are recommended to join the patient, and patients are advised to bring all medication with them, and if diabetic, their blood-glucose meter along as well. An MTM meeting is recommended once a year, unless the patient is prescribed a new medication and experiencing troubling side effects, a possible medication error, or if the patient is having monthly scheduled meetings the pharmacist.

Medication Therapy Management and the Prevention of Medication Error

December 28, 2010 | Lebowitz & Mzhen

According to the American Pharmacists Association (APhA), medication-related events are a massive problem to this country’s public health and well being. As our Baltimore medication error injury attorneys have reported in a related blog, according to the APhA, 1.5 million people are injured by medication errors every year, that cost around $177 billion in personal injury and death, and could be preventable.

Ed Webb, associate executive director of the American College of Clinical Pharmacy, recently stated that prescribed medication is only beneficial if taken correctly, and if medication therapy is not managed well, it can do harm. Webb, along with other experts, recommends medication checkups, known in the business as medication therapy management, or MTM.

As our Baltimore pharmacy error attorneys also discussed recently in a blog, more and more people are being encouraged to make appointments with their pharmacists as well as their doctors to discuss the medications that they take in an effort to prevent medication error, pharmacy misfill or patient injury.

Patients reportedly often end up saving money when meeting with pharmacists, by switching prescriptions to generic drugs instead of brand-name, or dropping medications that they may no longer need. Other patients are often able to eliminate medication side effects with help from a pharmacist on the best time to take the medication, possibly changing to a different drug, or avoiding a potentially dangerous mix-up of drugs, which can lead to expensive trips to urgent care or emergency rooms and result in personal injury.

CVS Pharmacy Misfill Mixes up Child’s Hyperactivity Drug with Methadone

December 22, 2010 | Lebowitz & Mzhen

In recent news that our Baltimore pharmacy error attorneys have been following, a nine-year-old child in Las Vegas reportedly received an accidental pharmacy misfill at a local CVS Pharmacy, after his hyperactivity medication was filled with methadone, a drug frequently used to treat withdrawal and dependence problems with people who are addicted to Heroin.

Tammy Jordan claimed that her son, Kyren, an active kid, is sometimes prescribed the drug Methylphenidate, to help treat his hyperactivity disorder. Jordan claims that she didn’t even check after picking up the prescription from CVS, as this was a common medication for her son.

According to KTNV.com, Jordan reportedly noticed that after Kyren had been taking the prescription misfill for an entire month, he couldn’t sit still, and couldn’t tell his mother why. A few weeks later, after dropping off the medication at Kyren’s school, the nurse called Jordan, and was alarmed that Kyren was taking Methadone and not Methylphenidate—the medication that the nurse regularly gave to the child.

Jordan claims that she was shocked by the medication error, and stopped Kyren from taking any more of the drug. He reportedly went through a period of withdrawal, but made a full recovery with no injury. Once Kyren recovered, she reportedly approached CVS, where the pharmacist on duty took the bottle and peeled off the first label, revealing that another label had been mistakenly placed on top of Kyren’s medication.

The state Board of Pharmacy is reportedly looking into the prescription drug misfill, to decide what exactly what happened, and how to prevent prescription filling errors from happening in the future.

In a recent blog our Baltimore pharmacy error injury lawyers discussed tips for preventing pharmacy misfills when picking up your child’s prescription at the pharmacy, including verifying the medication, always double checking the name on the prescription, the dosage, usage, and whether the drug is suitable for your child’s weight and size.