Advances in Patient Safety

Study Shows Barcode eMAR Technology Can Help Reduce Medication Errors

November 3, 2010 | Lebowitz & Mzhen

In a recent blog, our Maryland pharmacy error injury attorneys discussed reducing medication error and patient injury with barcode electronic systems, that link barcodes on the patient’s wrist bracelet with the patient’s electronic records and prescriptions, to ensure that the medication and dosage match the prescription for the patient.

According to a recent study that the Agency of Healthcare Research and Quality (AHRQ) in Rockville, Maryland, has funded, barcode technology, working together with eMAR, the electronic medication administration system, can help reduce medication errors by over 50%. The study was published earlier this year, in the May issue of the New England Journal of Medicine.

Barcode eMAR combines technology to ensure that each patient is given the proper medication with the correct dosage at the right time, in order to prevent medication errors or patient injury. When this combination of technology is used, before administering the medication, the nurses must scan the barcode on the patient’s wrist bracelet, and then scan the medication. If both barcodes don’t match the approved medication, or the timing is not correct for the patient’s next dose, an alert is issued by the system. If the patient’s medication is overdue, warnings are also sent out to the nurses.

In the study, researchers at Boston’s Brigham and Women’s Hospital compared 6,723 medication administrations given on hospital units before the barcode eMAR was introduced with the 7,318 administrations of medication given after the barcode system was introduced.

Children’s Hospital Launches Initiative to Prevent Medication Error

November 1, 2010 | Lebowitz & Mzhen

After two children died from medication errors at Seattle Children’s Hospital over a period of 18 months, as our Baltimore, Maryland medication error injury lawyers recently discussed in a blog, the staff of the hospital held a special ‘Zero Errors Initiative’ Patient Safety Day on Saturday, to prevent tragic medication errors like these from happening to children in the future.

According to the Seattle Post Intelligencer, over 550 physicians, staff, pharmacists, and nurses convened at the hospital for special patient safety sessions, focusing on training designed to prevent future incidents of medication and pharmacy errors.

Pat Hagan, the president of Children’s Hospital reportedly stated that these tragedies and the harm that was done to these children by the hospital will never be forgotten. Hagan said this has been a profound tragedy for the families, and for the hospital staff, and that this feeling will propel the hospital to continue to find ways to prevent life-threatening medication errors from happening.

The sessions during the safety training day included topics such as strengthening the safety of verbal orders, standardizing children’s medications located on care units, prescribing, dispensing and administering medications that are high-risk, improving communication between providers when handing off patients, and patient safety training with the use of simulation.

Preventing Prescription Errors: Consumer Reports Health Poll Finds Patients Want More Drug Information

August 30, 2010 | Lebowitz & Mzhen

Our Baltimore, Maryland pharmacy error injury lawyers have been following the results of a recent Consumer Reports Health Poll, that found that 65 percent of most Americans feel that drug makers have too much influence on doctors, and that doctors are too quick to prescribe drugs instead of exploring other non-drug options to manage health conditions. The poll also found that as patients, many Americans have a strong desire to acquire more drug information and safety details to prevent prescription errors in the future.

The Consumer Reports Health Poll found that:

• 45 percent of Americans take at least one prescription drug per day on a regular basis, and on average, they take around four prescription drugs.
• 39 percent of American consumers cut costs on personal healthcare in ways that might be dangerous and could lead to personal injury, with 27 percent failing to comply with drug prescriptions. In an effort to save money, 38 percent of individuals under the age of 65 who don’t have prescription drug coverage, failed to even fill the prescription.
• 87 percent of Americans stated that understanding the safety of a prescription drug was very important, and 79 percent of individuals were concerned about dangerous drug interactions. 78 percent worried about drug side effects.

• 47 percent of Americans said they think that pharmaceutical companies sway doctors’ choice of drug administration for patients based on gifts, and 41 percent of people stated that they think doctors tend to prescribe newer drugs that are more expensive.

According to the Institute of Medicine, at least 1.5 million drug errors occur every year in this country—errors that are preventable. John Santa, M.D. M.P.H., and Consumer Reports Health Ratings Center director, claimed in the study that Americans who are taking multiple drugs considered drug safety and side effects to be a high priority. The poll found that safety information provided in the pharmacy, doctor’s office or hospitals is not always comprehensive enough to prevent medication mistakes or drug error, and needs to be addressed.

Study Reviews Risk Levels Associated with Pharmacy Drug Dispensing

August 26, 2010 | Lebowitz & Mzhen

As Washington D.C. pharmacy error injury lawyers, we have been following recent study results released by the company Centice, that discuss the risk levels associated with drug dispensing processes, and the occurrence of pharmacy errors or misfills.

Centice is a company focused on the chemical verification of dispensed prescription drugs, and has recently published findings from that investigate levels of risk in the dispensing process for prescription drugs from Pharmacy Quality Assurance and Rx Verification Study.

According to the study’s research, after a single pharmacy error in the dispensing process, pharmacists can spend up to fifty hours correcting the dispensing error, or Quality Related Event (QRE).

Centice claimed that when looking at the total prescriptions filled, pharmacy error rates are very small, but when factored into dispensing many prescriptions over a period of time, given average pharmacy filling volumes, any prescription error that leaves the pharmacy can impact customer retention and the financial stability of the pharmacy, and could also lead to potential patient injury or even wrongful death.

ISMP Licenses MEDcounselor Drug Information to Prevent Medication Error

August 16, 2010 | Lebowitz & Mzhen

According to a press release that our Baltimore pharmacy error attorneys have been following, Gold Standard/Elsevier, a drug information and medication management solution developer, has licensed MEDcounselor Drug Information modules to the Institute for Safe Medication Practices (ISMP) for its consumer website, ConsumerMedSafety.org.

The ISMP is certified by the federal government as a non-profit safety organization of physicians, pharmacists and nurses that strive to prevent medication error and adverse drug events. ISMP offers confidentiality and legal protection for patients who submit safety and medication error reports, and claims that Gold Standard’s MEDcounselor modules are a valuable tool to help consumers become more engaged with their health care, and to make more informed medication decisions—which could prevent medication errors, and patient injuries and deaths on a worldwide basis.

The MEDcounselor modules available through ConsumerMedSafety.org include:

• Drug Information: When typing in the first three letters of the name of a drug, patients and consumers have access to medication information like side effects, important usage, and drug interactions for every prescribed prescription drug in the United States. Over-the-counter (OTC) drugs, vitamins, and nutritional supplements are also included in this information.
• MEDcounselor is written to comply with all national standards for Consumer Medication Information (CMI) and is available in both Spanish and English languages to avoid medication error.
• Drug IDentifier: If capsules or tablets become separated from the original package or container, consumers will be able to identify the drugs quickly by entering the imprint or marking that usually appears in the form of numbers. Patients can also select from thirty colors and twenty-five drug tablet/capsule shape choices for identification.
• Drug Interactions: Consumers and patients will be able to access possible drug interactions between prescription drugs, OTC medication, herbal and nutritional supplements, as well as any food intake, caffeine, alcohol and tobacco products that may interfere with the drug. Drug interaction alert include severity ranking that is color-coded for ease of use, and increases the clarity for the user.

Promoting Electronic Prescribing in Physician Practices

August 3, 2010 | Lebowitz & Mzhen

As our attorneys from Lebowitz and Mzhen Personal Injury Lawyers discussed in a recent blog, although e-prescribing usage has increased in recent years, many local doctors claim that the current e-prescribing systems, although helpful for reducing medication errors, can lead to more mistakes in prescribing.

According to Todd Rowland, M.D. and director of medical informatics for Bloomington, Hospital in Indiana, although the majority of electronic health records systems offer electronic prescribing as an option, some still charge a fee to doctors who use the electronic transmissions for prescriptions. In some instances physicians can send the prescriptions by fax for free, but then get charged to send prescriptions electronically. He also said that physicians are on tight time schedules, and systems that are new require additional steps, that are often overlooked.

Rowland also claimed that right now, many e-prescribing systems have unnecessary drug interaction alerts that pop up while a doctor is prescribing. He claims that as doctors have time-sensitive practices, the e-prescribing should provide high quality information, that prevents medication error, but also fits into their practice, without slowing them down.

Last year, the Center for Medicare and Medicaid Services (CMS) promoted the switch to electronic prescribing by paying doctors a bonus for e-prescribing. By 2012, doctors who are not e-prescribing with be financially penalized by the federal government. As we reported in a recent blog, President Obama’s economic stimulus this year included over $19 billion for health information technology, to help doctors and hospitals pay for the cost of electronic medical records systems and to help improve the safety, quality and efficiency of healthcare.

E-prescribing Usage Increases with Doctors, but Not Without Problems

August 2, 2010 | Lebowitz & Mzhen

As our Washington D.C. Pharmacy Error Injury Attorneys reported in a recent blog, physicians who are not prescribing medications electronically, or e-prescribing, by 2012 will be financially penalized by the federal government.

Although the use of electronic prescribing has increased in years, and evidence shows that e-prescribing can reduce pharmacy misfills that can lead to patient injury or even wrongful death, many local doctors reportedly clam that overall acceptance of this important technology is lagging.

According to a study published last week by the Washington-based think tank, the Center for Studying Health System Change, less than one-third of this country’s physicians in office settings, are e-prescribing. The study also revealed that even fewer physicians that were e-prescribing were using the beneficial aspects of the system, like searching for serious drug interactions and using the system to cross reference patient insurance for prescription drug verifications to ensure health plan payment coverage. The study also found that even fewer doctors who used the electronic system would actually prescribe medications electronically, opting to use the fax machine instead for prescription submittal.

The Institute of Medicine (IOM) claims 1.5 million people in this country are injured by preventable medication errors, with nearly 7,000 deaths every year.

USP Advisory Panel Pushes for Prescription Label Standardization

July 29, 2010 | Lebowitz & Mzhen

According to the Institute of Medicine (IOM), the misuse of medication results in over one million adverse drug events every year. In a recent blog, our attorneys discussed the current efforts made by the U.S. Pharmacopeial Convention (USP) to establish a universal standard for prescription drug labels and instructions, by issuing a series of recommendations in order to add more consistency to prescription labeling—to reduce medication errors that can result in personal injury or wrongful death.

The USP is a Maryland-based nonprofit organization that issues standards that are legally enforceable for the quality, strength, and purity of medicines in this country. In 2007, the USP developed the Health Literacy and Prescription Container Labeling Advisory Panel to examine the different ways prescription drug labeling could be improved.

The IOM claims that health literacy affects ninety million adults, who are unable to benefit properly from the health care due to a lack of understanding of drug instructions and information about medication interactions. After the IOM called for new drug label standards, the USP panel recently released recommendations that are based on patient well being, and health literacy—as bad health literacy can cause medication errors, and increase the potential for heath risks and personal injury.

According to Joanne G. Schwartzberg, co-chair of the panel, standardizing the medication labels can markedly improve the health and safety of patients, by providing reliable, simple and straightforward information. The USP panel recommendations cover the appearance, content, format and languages on prescription labels, in an effort to optimize patient understanding, and eliminate medication error and misuse.

Forum Guidance Leads FDA to Help Reduce Medication Errors

July 26, 2010 | Lebowitz & Mzhen

According to recent news that our Washington D.C. pharmacy error injury attorneys have been following, the U.S. Food and Drug Administration (FDA) has committed to reduce medication mistakes by publishing a draft guidance by the end of this fiscal year. The FDA states that one third of medication errors, including 30% of errors ending in deaths that are reported to the Institute of Safe Medication Practices (ISMP), may occur as a result of drug labeling and packaging.

The FDA reportedly claimed that medication errors often happen as a result of names that look alike or sound alike, encoded numerals, failure to recognize active ingredients, dangerous medical abbreviations, and name length.

In a FDA workshop last month, Carol Holquist, RPh and director of FDA’s Division of Medication Error Prevention and Analysis reportedly claimed that guidance on these medication mistake issues is an important first step to developing a consensus to form new FDA regulations, which can take around 10-15 years.

The American Society of Health-System Pharmacists (ASHP)’s director of Medication Use Quality Improvement, Bona Benjamin, also reportedly told the workshop group that the ASHP’s 2007 recommendations for the FDA are still current—that human factoring should be applied scientifically to drug packaging and labeling, and barcode verification should be encouraged, as nearly 20% of hospitals are using barcode medication verification.

Drug Alert Warns Epinephrine Syringe Shortage Could Lead to Dosing Error Risks

June 30, 2010 | Lebowitz & Mzhen

In yesterday’s blog, our medication error attorneys discussed a recent accidental overdose of epinephrine that led to a man’s death in a hospital. According to the FDA, Epinephrine is a high alert medication that could cause significant patient harm or injury when used in error. Medication error can occur when there is confusion in regard to epinephrine product ratio strengths. The Institute for Safe Medication Practices, ISMP, has received a number of fatality reports due to miscalculations of strengths of epinephrine injections.

In similar epinephrine news, the Institute for Safe Medication Practices (ISMP), and the American Society of Health-System Pharmacists (ASHP), announced a National Alert Network (NAN) message this month, to warn healthcare providers about dangerous medication mistakes that could be caused by a shortage of pre-filled epinephrine syringes.

The NAN warning states that emergency syringes of epinephrine in 1mg/10mL (0.1 mg/ml) are currently on backorder from the Hospira Inc., the only manufacturer of the product after the pharmaceutical company Amphastar stopped making its emergency syringes of the drug in 2009.

According to ASHP’s director of medication use, quality and improvement, Bona Benjamin, Epinephrine is a life saving drug used in ambulances, hospitals and any other emergency settings when a patient’s heart has stopped.

Benjamin claimed that the shortage of epinephrine does not effect quantities of the EpiPen, the epinephrine injection products that are self administered in .3 mg and .15 mg doses, to remedy severe emergency reactions to food, medication, insect bites, and other reactions of an allergic nature.