Common Errors

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.

Decimal-Point Mistakes Responsible for a Significant Number of Pharmacy Errors

August 8, 2017 | Lebowitz & Mzhen

Pharmacists rely heavily on an advanced command of mathematics to accurately fill prescriptions and avoid Maryland pharmacy errors. While some medications come pre-packaged, and all a pharmacist needs to do is double-check the physician’s instructions, other prescriptions require pharmacists to make small adjustments to dosage or administration instructions. This is especially the case in compounding pharmacies, which create specialized pharmaceutical compounds.

According to a recent industry news report, a significant number of pharmacy errors are caused by pharmacists incorrectly placing decimal points, or by the improper use of leading or trailing zeros. These errors, known as errors that involve a factor of 10, can result in a patient being given 10 times the required strength or one-tenth of the required strength, depending on the error.

The most common types of decimal point errors involve a pharmacist providing a patient with medication that is 10 times stronger than that which the patient’s physician prescribed. For example, if a physician prescribed a .5-mg dose, a pharmacist may miss the decimal point and provide the patient with a 5-mg dose. Of course, the dangers of this type of error are self-evident, especially when dealing with controlled substances.

Workplace Pressure Is a Key Factor in the High Rate of Maryland Pharmacy Errors

August 1, 2017 | Lebowitz & Mzhen

Pharmacists, like doctors and nurses, are medical professionals and are accordingly held to a high standard. This standard requires that pharmacists perform the duties of their job diligently, ensuring that patients are provided with accurate prescriptions and instructions on how to take their medication. When pharmacists make mistakes, anyone injured as a result of the mistake may be entitled to compensation through a Maryland pharmacy error lawsuit.

Pharmacy errors are responsible for tens of thousands of deaths across the United States each year, making it an important topic among researchers. The underlying causes of pharmacy errors vary, but according to a recent news article, workplace pressures are a major cause of pharmacy errors.

Historically, getting to the bottom of why pharmacy errors occur has been a difficult process, due to the lax reporting requirements. Indeed, the article explains that the number of pharmacy errors has remained constant over the past several years, but, due to changes in reporting requirements, the number of reported incidents has gone up. The researchers discovered that roughly 25% of all errors are caused by pharmacists providing the wrong medication to the patient, and another 25% of all errors are being caused by the pharmacist providing incorrect or unclear instructions on how to take the medication.

New Study Shows Increase in Medication Errors Occurring at Home

July 24, 2017 | Lebowitz & Mzhen

When researchers look into the causes of medication errors, errors are broken down into several categories. Two of the main types of Maryland medication errors are errors that occur in a hospital setting and those that occur in a patient’s own home.

When researchers refer to at-home medication errors, they are referring to prescriptions that are picked up at retailer hospital pharmacies and brought home, where the patient takes the medication without supervision. Hospital medication errors, on the other hand, are usually administered by a nurse or another medical professional while a patient is in in-patient care.

According to a recent study, the rate of at-home medication errors has been going up in the past few years. Researchers note that back in 2000, the medication error rate was 1.09 in every 100,000 patients. However, in 2012, that figure rose to 2.28 patients across all patient demographics except young children under the age of six. Researchers note that the errors most commonly involve cardiovascular drugs, analgesics, and hormone therapy medication.

Handwritten Prescriptions Show High Rate of Prescription Errors

July 17, 2017 | Lebowitz & Mzhen

Maryland prescription errors can occur at different stages in the prescription process. One of the ways errors can occur is when a pharmacist misinterprets the doctor’s handwriting on the prescription form. Errors can also occur when a doctor handwrites a prescription but forgets to include certain pertinent information.

Even when a prescription error is not fatal, it can still seriously affect a patient’s safety and quality of health. Advocates have encouraged doctors to reduce prescription errors by introducing automated systems, uniform prescribing charts, and immediate review of prescriptions. Some argue that in addition to improving the readability of prescriptions, electronic prescriptions can also help by providing the doctor with optimal dosages.

Study Finds Handwritten Prescriptions Contain More Mistakes than Electronic Prescriptions

According to one news source, a recent study looking at opioid prescriptions found that there were more mistakes in written prescriptions than in electronic prescriptions. The study looked at prescriptions filled at a pharmacy at Johns Hopkins Hospital. The researchers sought to determine whether prescription processing methods contributed to inconsistencies and errors in opioid distribution. The researchers reviewed all of the prescriptions processed for adults during a 15-day period. There were 510 prescriptions in total. The study evaluated the prescriptions based on three criteria: compliance with best practice guidelines, which include standards such as legibility and including the date; the inclusion of at least two patient identifiers; and compliance with federal opioid prescription rules, which require including the patient’s full name and address.

Pharmacy Errors Involving Expired Medication

July 10, 2017 | Lebowitz & Mzhen

Pharmacists are responsible for ensuring that the prescriptions they fill are correct. Of course, this means that pharmacists must take care to provide patients with the correct medication, at the correct dose, and with the appropriate dosing instructions. To be sure, most medication errors involve an oversight involving one of these issues. However, according to a recent news article, a pharmacist in New Zealand recently provided one patient with a three-month supply of medication that was just one month away from being expired.

Evidently, a patient went to the pharmacy to fill a prescription of Ferrograd. When the pharmacist provided the patient with the requested three-month supply, the pills provided to the patient were to expire in one month. A few months later, the patient went back to refill another prescription. This time, the pharmacist gave the patient the wrong drug entirely. At this time, the patient double-checked her Ferrograd prescription and realized it was expired. She returned the prescription for a replacement.

The supervisory board found that the pharmacist failed to fulfill the duty that was owed to the patient, and it implemented an investigation into the pharmacy’s practices. The pharmacy explained that whoever dispensed the prescription wrote down the incorrect drug name and retrieved the incorrect pills from a similar-looking bottle. The pharmacist ended up acknowledging her mistake and providing the patient with a written apology.

Pharmacy Errors Involving Look-Alike and Sound-Alike Drug Names

June 22, 2017 | Lebowitz & Mzhen

Pharmacy errors have been on the rise over the past few years. While there are many reasons why a pharmacist may give the wrong medication to a patient, one of the most commonly reported causes of pharmacy errors is look-alike and sound-alike drug names.

The pharmaceutical industry relies heavily on marketing to sell medication. Once a medication is established as effective and becomes popular, other medications that perform a similar function may be released with similar-looking or -sounding names. This can create a dangerous situation when a busy pharmacist needs to fill multiple medications for drugs that all sound the same, each with its own dosing requirements and instructions.

The Government’s Efforts to Curb Pharmacy Errors

According to an article in a recent industry publication, the Food and Drug Administration’s Division of Medication Error Prevention and Analysis (DMEPA) has recently ramped up its efforts to review drug labels prior to FDA approval in hopes of decreasing the total number of errors due to look-alike and sound-alike drugs.

Long Hours and Stressful Working Conditions Contribute to Pharmacy Errors

June 15, 2017 | Lebowitz & Mzhen

Pharmacists have a great deal of responsibility in that they are responsible for accurately providing patients with physician-prescribed medication, double-checking that their prescribed medication does not negatively interact with other medications, and advising patients with medication-related advice. There can be little doubt that pharmacists have their hands full. This is especially the case when pharmacies are understaffed or during unusually busy hours.

According to a recent news report, the long hours and stressful work conditions present in many pharmacies across the country result in an increased risk of potentially serious errors. The article interviews several retired pharmacists, who relay their concerns about how the industry has become more demanding on pharmacists, often requiring that they work 14-hour shifts with only a few short breaks.

With drive-thru windows becoming more common over the years and the pressure to keep the pharmacy’s bottom line in mind, pharmacists not only are working long hours but are highly stressed while on the job. By some estimates, pharmacies are filling up to 800 prescriptions per day. These factors, according to the pharmacists interviewed in the article, have contributed to an increase in errors over the past several years. However, due to a lack of regulations, pharmacies are not required to report most of these errors, resulting in a dearth of accurate official statistics.

The Lack of Pharmacy Regulations May Result in an Increased Risk of Error

May 15, 2017 | Lebowitz & Mzhen

In some ways, the pharmaceutical industry is heavily regulated. Medications must undergo years of testing before they are released and available for prescription. Similarly, pharmacists themselves must obtain a specialized advanced degree and have a certain amount of on-the-job training before they are certified. However, pharmacy technicians require less training and are often permitted to fill prescriptions on their own, requiring only a brief glance by the overseeing pharmacist before being provided to the patient.

According to a recent news report, a lack of regulations inside the pharmacy may be responsible for the increase in pharmacy error rates across the country. The report details one woman’s experiences after being prescribed a dose of a prescribed medication. The report notes that lawmakers in many states have not enacted rules limiting the number of prescriptions a pharmacist can fill per hour or per day. This means that, rather than being permitted to focus on assuring that each prescription is properly filled, a pharmacist may be pressured by management to fill large amounts of prescriptions. This emphasis on quantity over quality can have disastrous results.

Prescription Error Results in Patient’s Skin “Melting Off”

Earlier this month, a local news report documented one woman’s struggles after being prescribed the wrong dose of the medication lamotrigine. According to the report, the woman went to the doctor because she felt depressed. The doctor wrote a prescription for lamotrigine, and the woman took it to her local pharmacy. However, the pharmacist on duty incorrectly filled the woman’s prescription at the wrong dose.

Pharmacy Errors Occurring After a Transition to Long-Term Care

May 8, 2017 | Lebowitz & Mzhen

The dangers of prescription drugs have been well-documented over the past several decades. In most cases, a medication is made available only by prescription because it presents an increased risk of causing harm to a patient who should not be taking it. This can be due to an increased risk of negative interaction with other medications, an increased risk of abuse, potential side effects, or the ease with which a patient could accidentally overdose.

Prescription errors can occur any time a patient is given medication. While many of these errors occur at local retail pharmacies, a large percentage of prescription drug errors occur in long-term care facilities. Once a patient is discharged from the hospital, their medical records are supposed to follow them. However, the reality is that many of the prescription errors that occur in long-term care facilities occur shortly after a resident is discharged from the hospital. This is most often due to a miscommunication between the hospital and the long-term care facility.

A recent report discusses how the period of transition from hospital to long-term care facility is one of the most dangerous times for patients. The report notes that in many cases, patients in transition are in “crisis mode,” after having recently been admitted to the hospital. The patient most likely has seen several medical professionals, and they may be taking multiple prescription medications that they are not accustomed to taking. Thus, the patient is less likely to be able to catch an error before it occurs.