Common Errors

Recent Study Links Medication Errors to Sound-Alike Drug Names

August 8, 2016 | Lebowitz & Mzhen

It should come as no surprise that pharmacists are busy professionals. Often filling thousands of prescriptions a week for hundreds of clients, keeping everything straight can be a difficult task. However, it is one that pharmacists take on willingly. It is also a task that they are legally obligated to complete accurately. In other words, when a pharmacist makes a mistake with a patient’s medication, the pharmacist who filled the prescription, as well as the pharmacy that employs the pharmacist, may be held financially liable for any injuries as a result of the error.

The causes of medication error are not generally a lazy or uncaring pharmacist. In fact, according to a recent study, the causes of many pharmacy errors are that there are too many prescription drugs with similar names. According to one news report covering the new study, look-alike and sound-alike drug names are a real problem in the pharmaceutical industry.

The Study

The study took a group of pharmacists, nurses, doctors, technicians, and lay people, and it attempted to determine if mix-ups occurring in the labs (before a drug is released to the pharmacy) can be predictive of future errors that may occur in real life. The results of the study were not surprising in that similar-looking or similar-sounding drug names will result in an increase in error rates.

Fatal Pharmacy Errors and the Parties Responsible for Preventing Them

July 1, 2016 | Lebowitz & Mzhen

Pharmacy errors are an unfortunately common phenomenon across the United States. Most often, these errors stem from a single problem: a lack of oversight. Often, serious pharmacy errors occur due to a busy pharmacist or pharmacist technician filling an order in haste, rather than taking the proper amount of time and double-checking their work. Ultimately, the responsibility for these errors falls not only on the pharmacist technician making the mistake but also on management in charge of supervising that pharmacist’s work.

In fact, the responsibility for a serious or fatal pharmacy error may lie with several parties. Depending on the specific facts involved in each case, liability may lie with the pharmacist, the management of the pharmacy, and potentially even with other supervising organizations. A recent article discussing a situation in Canada gives an example not often seen here in the United States, but one that could possibly arise.

First Nation Leaders Concerned over Dozens of Deaths Tied to Pharmacy Errors

Over two dozen First Nation citizens in Canada have died at least in part due to pharmacy errors that have occurred over the past 10 months. According to a local news source covering the deaths, all First Nation people in Canada have a specific company that oversees all their prescription drug needs. This company has a contract with the Canadian government.

Customer Service at Specialty Pharmacies May Be an Issue for Some Patients

June 15, 2016 | Lebowitz & Mzhen

As business practices across the board evolve, so does the pharmacy industry. And with brick-and-mortar pharmacies requiring high month-to-month operating costs, mail-order pharmacies are becoming more common as a way for some patients to save money on their costly prescriptions. With the increase in popularity of mail-order pharmacies, more and more people are getting experience dealing with these companies, which do not present any opportunity for face-to-face interaction.

The truth of the matter is that pharmacies – regardless of where they are based – have a duty to their patients to accurately fill all prescriptions. And if a mail-order pharmacy can save customers money on prescriptions by not needing to pay real-estate or rental costs, that is fine, but pharmacies should not cut corners when it comes to staffing or customer service. However, that is exactly what one woman experienced when trying to secure her husband’s necessary daily medications from one mail-order pharmacy.

According to a recent article by Forbes, customer service at some mail-order pharmacies may be so poor that it puts patients in danger of running out of necessary medication. The article details the plight of a woman whose husband had recently been diagnosed with Parkinson’s Disease. Aside from dealing with the life-changing realizations the diagnosis brought, the couple also had to find a way to ensure a steady supply of the husband’s extremely expensive day-to-day medications.

What to Do if the Pharmacist Gives You the Wrong Medication

March 1, 2016 | Lebowitz & Mzhen

Ideally, pharmacists would always provide their patients with the correct medication and dosing instructions. However, that is not the reality we live in. It seems as though each week several new reports of prescription errors arise, some with serious or fatal consequences. While the duty to prevent these errors lies with the pharmacist, there are some steps that can be taken to help reduce the frequency of pharmacy errors. In addition, there are also steps that should be taken once a prescription error is noticed.

According to a recent report, there are over 100,000 deaths each year from adverse drug interactions. Many of these are the result of a pharmacy error. In fact, it is estimated that each year, there are about 7,000 preventable fatalities due to mistakes made in a pharmacy setting. Pharmacists and the pharmacies that employ them may be held accountable for their mistakes through civil lawsuits based on the legal theory of negligence. However, how a victim of a prescription error handles the moments after discovering an error may affect the viability of any personal injury claim in the future. Thus, it is important that certain steps be taken after noticing that you have been provided the wrong medication by a pharmacist.

What to Do in the Wake of a Prescription Error

First, and most importantly, seek out medical treatment immediately. While some pharmacy errors are relatively benign, others can be fatal, depending on the patient as well as the medication. Patients should not attempt to treat themselves and should let a medical professional assess the situation.

Pharmacists’ Reactions to Reported Medication Errors

February 8, 2016 | Lebowitz & Mzhen

Mistakes happen. Despite the best efforts of pharmacists and pharmacy technicians, sometimes an error will occur, and a patient will be provided with the wrong medication, or provided with the right medication but with inaccurate instructions on how to take it. In these cases, patients will almost always first reach out to the filling pharmacist to determine whether an error occurred and whether they should immediately go to the hospital. When pharmacy staff denies the error or tries to push the mistake onto someone else, patients understandably get frustrated.

On one hand, it makes sense why a pharmacist would initially deny liability when hearing that a medication error occurred, since if any injuries result from the error, they could be held personally and professionally liable. In addition, the pharmacy that employs the technician can also be held liable. In fact, in some cases the financial liability for medication errors can reach into the hundreds of thousands of dollars, if not millions, in cases when a serious injury or death is the result. However, avoiding responsibility or hiding the truth from the patient is certainly not the best practice.

Pharmacists Encouraged to Have Detailed Procedures in Place for Reported Errors

Earlier last month, a pharmaceutical industry news source reported on how pharmacies should consider putting detailed protocols in place for handling reported medication errors. The article documents one woman’s experience filling a prescription for 20 mg pills of amitriptyline. Instead of filling the prescription with the 20 mg pills the doctor ordered, the woman was provided 200 mg pills by the pharmacist on duty.

Statutes of Limitations in Pharmacy Error Cases

December 9, 2015 | Lebowitz & Mzhen

Almost all personal injury cases must be brought within a certain amount of time. The laws that set forth the specific amount of time in each type of case are called statutes of limitations. A plaintiff’s failure to bring a suit in the applicable amount of time under the statute of limitations can mean that the plaintiff forever loses the ability to bring that case.

Maryland Pharmacy Error Cases

Under Maryland law, personal injury and medical malpractice cases must be brought within either three or five years, depending on the specific circumstances of the alleged injury and when it was discovered by the plaintiff. Under the general rule, a lawsuit must be brought within three years of the discovery of the injury. However, no claims will be allowed after five years of the date of the injury.

When the “clock” starts ticking is sometimes up to interpretation. For example, in some pharmacy error or medical malpractice cases, the plaintiff’s injury is not immediately apparent. In these cases, the plaintiff will have up to five years from the time the injury occurred to bring the lawsuit. Importantly, this may be different from when the injury was discovered by the plaintiff.

Woman’s Depression Worsens after Being Provided the Wrong Medication

November 24, 2015 | Lebowitz & Mzhen

Earlier this month in New Zealand, a woman who was traveling throughout the country suffered worsening depression and potentially other long-term side effects after a pharmacist provided her with the wrong medication. According to one local news source, the woman went to see a general practice doctor who refilled her prescription of an SSRI medication used to treat her depression.

Evidently, the woman took the refill to a nearby pharmacy to get it filled. However, the filling pharmacist provided the woman with Duride instead of the SSRI medication. Duride is a cardiac medication typically used to treat angina. The error, however, was not immediately discovered. It took some time for the woman to notice a worsening in her depression. She began to once again suffer from anxiety, migraines, and heart palpitations. Her relationship broke down, and she was unable to find a job. She eventually went back to the doctor, who upon seeing the packaging of the medication she was taking, immediately knew it was not the SSRI she had been prescribed.

The doctor notified the pharmacy of the error. The pharmacist has since told reporters that there was “no explanation” for the mix-up. He also noted that, at the time of the error, the two medications had similar packaging and were near each other on the shelf. The pharmacist took full responsibility, noting that the pharmacy technician that day was not involved in the error, and he also apologized to the patient for the error.

Pharmacists’ Performance Evaluation Metric Acts Like a “Quota System” to Reward Speed Over Precision

October 19, 2015 | Lebowitz & Mzhen

Pharmacies, like other businesses, are operated for profit, and labor is one of the main expenses for a pharmacy. Therefore, a pharmacy that hopes to remain profitable will likely try and provide only enough pharmacists who will be able to fill the prescriptions for the patients who come through the door. Excess pharmacists means the pharmacy is losing money in labor costs.

However, as one recent industry news source points out, the evaluation metric being used by some pharmacies feels a lot like a quota system where pharmacists are pressured into fill prescriptions as quickly as possible. This, of course, could have a detrimental effect on the pharmacist’s accuracy.

Pharmacy Errors Across the Country

Each year, there are an estimated one million medication errors that occur throughout the United States. Of those patients that are provided with an inaccurate medication, about 7,000 will die each year. This makes prescription errors one of the top 10 leading causes of death in the country.

Pharmacist Mistakenly Provides Chemotherapy Drug to Elderly Patient and Then Tries To Cover Up His Mistake

October 7, 2015 | Lebowitz & Mzhen

Earlier this month in New Zealand, a pharmacist was reprimanded by the governing professional board after it was discovered that he made an error in providing a patient with the wrong medication and then tried to cover up his mistake. According to one industry news source, the pharmacist accidentally provided an elderly patient with a chemotherapy drug rather than his prescribed immunosuppressant medication.

Evidently, the elderly patient had recently undergone a kidney transplant and was prescribed an immunosuppressant as a part of his recovery. However, when the man went to fill the prescription, he was provided a chemotherapy drug instead. It was not until three weeks later that the man returned, asking the pharmacist why his pills had changed, that the pharmacist discovered that there may have been an error. He told the patient to stop taking the drug.

Upon investigating the error, the filling pharmacist discovered that he was the one who had filled the prescription. Once he realized that he had made the error, the pharmacist failed to report the error. The Deputy Health and Disability Commissioner, who oversees pharmacists, explained to reporters that the pharmacist should have provided the patient with counseling as well as reported the error. It was not until the pharmacy owner later discovered that the chemotherapy drug supply was depleted that management knew there had been an error. He then made the appropriate report.

FDA Changes Labels on Anti-Bacterial Drug Due to Potential for Easy Mix-Up

September 29, 2015 | Lebowitz & Mzhen

Earlier this month, the Food and Drug Administration (FDA) announced a warning regarding the confusing packaging on the intravenous antibacterial drug Avycaz. According to one industry news source, the announcement was made after there were several reports of errors made in the dosing of the drug to patients. Evidently, the strength of the medication that was listed on the outside of the carton or vial was difficult to decipher for pharmacy personnel.

The confusion apparently arose because of the way that the label listed which substances were actually contained inside each package. Avycaz contains two active ingredients, ceftazidime and avibactam. The previous labels list each separate ingredient and its amount next to the drug’s name. For example Avycaz 2g/.5g means that the drug contained 2g of ceftazidime and .5g of avibactam. The new label will be more descriptive, explaining that the package contains a total of 2.5g of medication, which consists of 2g of ceftazidime and .5g of avibactam.

The Reported Errors

According to the article, there had been three reported errors since the drug’s approval back in February of this year. Two of the errors occurred as the drug was being prepared by the pharmacist, while the third arose due to the confusion in the language on the drug’s packaging. The FDA reported that at least one patient received and ingested a higher-than-prescribed dose, but there had been no adverse effects reported.