Common Errors

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.

New Study Looks at Error Rates in Hospital Pharmacies

September 22, 2015 | Lebowitz & Mzhen

Earlier this month, a study was released in the American Journal of Health Systems Pharmacy that looked at error rates in hospital pharmacies. Specifically, the study considered the link between the number of incoming orders over the course of a given shift and the prescription error rate. Not surprisingly, the results of the study indicated that the busier the pharmacy, the more likely that there would be a pharmacy error made.

The study took place in Houston, Texas, between July 1, 2011 and June 30, 2012. Over the course of the study, over 1.9 million prescriptions were filled by about 50 pharmacists. In total, there were 92 prescription errors recorded.

Prescription Drug Recalls Based on Faulty Childproof Packaging

September 15, 2015 | Lebowitz & Mzhen

Earlier this month, a prescription drug designed and marketed for the treatment of some kinds of cancer, including brain cancer, was recalled because a number of the bottles that contained the drug had faulty caps. According to one industry news report, the caps of approximately 1,100 bottles of the prescription drug, Temozolomide, have the potential to crack, nullifying the childproof nature of the cap.

Evidently, the side effects of the medication are potentially severe, even for adults, and can include respiratory failure, terminated pregnancy, infertility, severe vomiting, and nausea. To ensure that the medication is not ingested by curious children, the U.S. government requires that potentially dangerous drugs like Temozolomide are packaged in childproof packaging. However, for an unknown reason, the caps on a significant number of these bottles were defective.

Specifically, the bottles that may be in danger of having cracked lids were sold between July 2013 and August 2015. The bottles at issue are the five- and 14-count brown bottles with black lettering. Merck, the manufacturer of the drug, has told patients to inspect the caps of their medication and to remove the bottles from the reach of children. In addition, Merck has suggested that all pharmacists who handle bottles of Temozolomide double check to ensure that the caps are in good condition. Of course, any bottle that does have a cracked lid should not be distributed to a patient.

Causes and Effects of Pharmacy Errors

August 14, 2015 | Lebowitz & Mzhen

Picking up a prescription at the local pharmacy is something almost everyone has the occasion to do at some point in their life. In fact, many people pick up multiple prescriptions per month. Picking up a prescription that was provided or filled in error seems to many to be one of those situations that “couldn’t happen to me.” However, as a recent article points out, prescription errors are more common than most people think, and they can often have dire consequences if they are not caught immediately.

Common Causes of Prescription Errors

The causes of prescription errors are several, but certain causes appear again and again in studies. The volume of prescriptions that pharmacists and pharmacist technicians must fill on a daily basis results in a high-stress environment where little time is left to double-check one’s work.

A rushed pharmacist is likely working to fill several customers’ orders at a time and may cut corners to save time. However, that type of behavior can increase the risk of providing an incorrect medication to a patient, such as either of the following examples:

Alert Fatigue Shown To Be a Major Factor in Many Pharmacy Errors, Solutions May Be Coming

June 15, 2015 | Lebowitz & Mzhen

Whenever a pharmacist is filling a prescription, if there is the potential that the medication they are providing to a patient may have an adverse interaction with another medication, should be taken with specific instructions, or is otherwise potentially dangerous, an alert will pop up on the pharmacist’s screen. However, given that most medications are dangerous under some circumstances, and pharmacists can fill hundreds of prescriptions a day, theses alerts tend to bog a busy pharmacist down.

What is Alert Fatigue?

According to a recent industry report, alert fatigue occurs when a pharmacist is so accustomed to seeing an alert pop up that they almost automatically disregard the alert as unimportant. Reasons for dismissing the error vary, but the end result is the same. The patient ends up taking the prescription home and consuming it, leading to a potentially disastrous situation. As one can imagine, alert fatigue is the cause of a substantial number of pharmacy errors, since pharmacists are substituting their own on-the-fly judgment for the tried and true research of medical professionals.

What Can Be Done About Alert Fatigue?

Given that alert fatigue is a real problem in pharmacies across the United States, there has been a concerted effort by some in the industry to address the issue. One potential solution, according to the article discussed above, is the implementation of software that provides more accurate, more specific, and more targeted alerts. These new programs may also provide a “threat-level” for the pharmacists, so they are able to tell how serious an alert really is.