Common Errors

New Study Finds that Two-Thirds of Pharmacists Miss at Least 20% of Dispensing Errors

September 15, 2014 | Lebowitz & Mzhen

According to a study that was recently conducted in the United Kingdom, pharmacists miss errors in prescriptions in a frightening number of cases. According to a report by the Pharmaceutical Journal, the study results were unveiled at the Royal Pharmaceutical Society Annual Conference earlier this month.

The study took 103 local pharmacists and had them fill 50 prescriptions in 25 minutes, which is generally considered a normal, if slightly heavy, workload for that amount of time. Five of the 50 prescriptions intentionally contained errors. There were also a few distractions that were thrown at the pharmacists while they were filling the test prescriptions, but nothing out of the ordinary for the profession.

The idea of the study was to see how many of the pharmacists would catch all five of the errors. The results were frightening. Below is a summary of the results:

Confusing Drug Names May Lead to More Prescription Drug Errors

August 20, 2014 | Lebowitz & Mzhen

Prescription drug injuries are becoming more and more common as pharmacies try to meet the increasing demands of their customers without hiring additional staff members. While there are several potential causes for a pharmacy misfill, one recent article points out that the similarity of different drug names may play a role in the confusion, increasing the chances of an error.

Confusion Can Lead to Serious Injury or Even Death

Although some medication errors can cause little or no harm to the patient taking the drug, others can cause permanent or serious injury or even death. Suppose that the prescription is for a life-threatening condition that, if the patient does not get his or her medication, he or she could die. If a pharmacist fills that patient’s prescription with the wrong drug—even if the improperly prescribed drug was harmless—the patient may suffer serious injury or death.

Dosage confusion is also an area that can result in serious injury. If a doctor improperly prescribes a larger-than-needed dose, and the patient takes the prescribed dose, he or she may be at risk of an overdose. The same is true for an under-dose.

Study of “Collaborative Pharmaceutical Care” Finds 3/4 Reduction in Hospital Medication Errors

March 19, 2014 | Lebowitz & Mzhen

A new study, conducted in Irish hospitals and published in a British journal, reviewed the effectiveness of a “collaborative” model of managing hospital patients’ medications. The model, known as the Collaborative Pharmaceutical Care in Tallaght Hospital (PACT), involves close involvement of clinical pharmacists in all stages of patient care during their stay in the hospital. The study, which was uncontrolled, found that PACT resulted in a reduction in the rate of medication errors by more than three-fourths.

The study was published in the online edition of the British Medical Journal Quality & Safety on February 6, 2014. The researchers compared the benefits of PACT to “standard ward-based clinical pharmacy,” with a focus on adult hospital patients receiving acute care, who were prescribed at least three medications in the hospital, and who left the hospital alive. The study included 112 patients receiving care based on PACT, and 121 patients receiving standard care. They measured the rates of medication errors and of potentially severe errors per patient.

According to the description provided in the study, the primary goal of PACT is to reduce the rate of medication errors that commonly occur when a patient is transferred between doctors or departments within a hospital, or transferred from one facility or organization to another, by improving the process of “medication reconciliation” (MedRec). This involves comparing a patient’s current medication orders to the medications a patient has been taking in order to prevent omission of a necessary drug, inclusion of an unnecessary or dangerous drug, or incorrect dosages.

Washington DC News Investigation Finds Multiple Medication Errors at National Pharmacy Chain

February 27, 2014 | Lebowitz & Mzhen

In a report on its investigation of the national pharmacy chain CVS/pharmacy, Washington DC’s NBC affiliate, News 4, claims to have found numerous alleged medication errors and other problems. Consumers reported receiving the wrong prescription and, in at least one case, meeting with indifference from employees. A former CVS pharmacist with more than thirty years at the company filed a whistleblower lawsuit last year, alleging in part that the company fired him in retaliation for reporting his concerns about an increasing rate of medication errors due to staff reductions. CVS has denied the allegations against it and publicly stated its commitment to protecting patients’ health and safety.

Washington’s News 4 reported a woman’s claim that CVS made a mistake when refilling her prescription for potassium citrate, which she took for her kidneys. She noticed that the pills did not look familiar, and saw that the pharmacy had given her a bottle of potassium chloride instead of citrate. The pills look similar and have similar names, but they have very different uses. Potassium chloride is used to treat hypokalemia, or low blood potassium, and can cause serious, even fatal, complications for some kidney patients. The woman claimed that when she notified the pharmacy manager of the mistake, he responded “Well, potassium is potassium.”
The report also looked at automatic refills, a service offered by CVS and other pharmacies. This allows the pharmacy to refill a prescription at regular intervals, so that the patient does not have to call and request a refill. Problems may occur, however, if the pharmacy refills prescriptions that the patient does not want or need. An elderly patient told the news team that he ended up with more Lidoderm patches, which contain an extremely strong painkiller, than he wanted, based on the auto refill system. This could lead to confusion for some patients, who might not realize that they are receiving medications they did not request.

Pharmacy Allegedly Dispenses Adult’s Prescription to Child with the Same Name, Resulting in Near-Fatal Drug Reaction

February 20, 2014 | Lebowitz & Mzhen

The family of a five-year old boy in the Chicago area is claiming that a case of mistaken identity resulted in the boy receiving the wrong medication and suffering a near-fatal reaction with possible long-term health effects. They have filed a negligence lawsuit in Cook County Circuit Court seeking $50,000 in damages. Pharmacies and the medical professionals they employ owe a duty of care to consumers to verify not only the type and dosage of medication dispensed, but also that the correct patient receives the correct medication.

The child reportedly had a routine checkup with a physician in January 2012. The doctor discussed allergy medication with the boy’s parents, but did not write a prescription at that time. A Walgreens pharmacy allegedly called the family two days later to tell them that their prescription was ready. Believing it to be the allergy medication they had discussed with the doctor, the boy’s mother picked the prescription up and began giving it to him according to the instructions on the bottle.

The lawsuit, filed in January 2014, states that the boy slept for almost two full days after taking the medication. When the child woke up, he exhibited unusual symptoms. His neck flared, leading his parents to call 9-1-1, but it soon subsided. The boy later fainted, so his parents took him to the doctor, who told them to go immediately to the hospital. The prescription that they thought was for allergies, they learned, was actually haloperidol, an antipsychotic medication intended for an adult with the same name as the child.

Similar Drug Names Can Cause Confusion, Catastrophe if Pharmacy Makes an Error

January 15, 2014 | Lebowitz & Mzhen

Confusion between two similarly-named drugs can be harmful or even fatal if the error is not detected quickly. An error could result from any number of circumstances, such as a pharmacist who misreads a doctor’s handwriting or a nurse who accidentally administers the wrong drug. The U.S. Food and Drug Administration has procedures for comparing new drug applications to existing drugs, but this does not guard against confusion regarding drugs that are already on the market. A pharmacy journal published an account last year of one such medication error at an oncology clinic, which fortunately did not result in any complications for the patient who received the wrong medication. A version of the drug she received, however, has been implicated in numerous injuries and lawsuits.

The journal Hospital Pharmacy included an account in its June 2013 issue of a fourteen year-old girl diagnosed with acute promyelotic leukemia (APL) who received the wrong medication for about four months. APL, according to the authors, can quickly turn fatal and requires immediate treatment. Her doctors prescribed an oral dose of trentinoin, a vitamin A derivative commonly prescribed in a topical form under the name Retin-A to treat and prevent acne. It is administered orally in 10-miligram capsules to treat APL. The same basic effect that treats acne can also fight cancer cells.

After completing a course of treatment, the patient returned to the hospital about a month later. Her doctors decided to do several rounds of outpatient intravenous chemotherapy and continue the oral trentinoin. A nurse in the oncology clinic, possibly unfamiliar with the drug, instead called in a prescription for isotrentinoin under the brand name Claravis. While similar to trentinoin, isotrentinoin is primarily used to treat severe acne. It was formerly marketed as Accutane, but the manufacturer discontinued the brand in 2009, allegedly in part because of lawsuits claiming harmful side effects.

Common Abbreviation of Acetaminophen Causes Potentially Deadly Consequences

October 9, 2013 | Lebowitz & Mzhen

A doctor/medication safety specialist recently wrote an article about a common abbreviation that could lead to severely adverse consequences in patients. The article, which appears in the web version of the Pharmacy Times, discusses one common abbreviation for acetaminophen, APAP, which is based upon the chemical composition of the drug, that could lead to a deadly overdose when patients take other medications not knowing that they contain the same drug.

For example, in one case following surgery, a 56 year old man was prescribed a hydrocodone/acetaminophen combination drug, but on the label it was abbreviated Hydrocodone/APAP. The instructions said to, “take one tablet by mouth every 4 to 6 hours as needed for pain.” The patient took the medication as instructed, but had insufficient pain relief, so he began taking additional over the counter acetaminophen, and followed those instructions, taking two caplets every 4 to 6 hours as needed.

Following some four days of this combination, the patient returned to the doctor for his post-op appointment, he complained of a lack of appetite, nausea, vomiting, and abdominal pain. The doctor was able to determine that the man was taking over 8 g of acetaminophen per day. The patient told the doctor that the pharmacist did not counsel him on the daily limit of acetaminophen, and that he was unaware that his prescription also contained acetaminophen. The patient was subsequently admitted to the hospital and treated for acute hepatotoxicity, and he luckily made a full recovery.

Report Reveals 36 Serious Incidents of Harm from Medication Related Errors

August 13, 2013 | Lebowitz & Mzhen

Ontario hospitals recently released a new report detailing some 36 incidents that occurred last year where medication-related mistakes led to patients suffering severe harm or even death.

Among the reported incidents, patients were harmed when given incredible overdoses of narcotic painkillers, received the incorrect drug, or were administered an additional (and therefore dangerous) dose.

Of all of the incidents, ten patients died, while the remaining 26 suffered harm so severe that it required life saving interventions to correct, caused a major disability, or led to a shortened life span.

New Heparin Labels Intended to Reduce Fatal Overdoses

July 25, 2013 | Lebowitz & Mzhen

A recent article in Pharmacy Practice News discussed ways in which updated labeling standards for Heparin Sodium Injection and Heparin Lock Flush Solution may not eradicate the problems associated with overdose completely. One major reason being that some of the older problematic versions of the label remain in pharmacy stocks.

According to information on the relevant organization’s website, the new labeling requirements, which took effect this May, require that the new heparin products clearly indicate the concentration of the medication, followed by how much medication is in each milliliter (mL).

Prior labels stated the per mL amount, with the total container volume appearing elsewhere, thus leading to errors when practitioners mistook the per mL amount as the total volume in the vial. This sort of mistake led to dangerous heparin overdoses.

For example, in one case a patient died due to bleeding in the brain, which occurred as a result of two practitioners mistakenly thinking that a 10-mL vial of heparin held a total of 1,000 units, when each vial actually contained 10,000 units (1,000 units/mL). As a result, they administered 30,000 units to the patient instead of 3,000.

Dangerous Drug Disaster Narrowly Avoided When Vitamin Substituted with Resuscitation Medication

July 11, 2013 | Lebowitz & Mzhen

A Washington woman narrowly avoided a potentially tragic prescription error, when she picked up her usual prescription for the vitamin B12. The label on both the bag and the container even contained the correct name: Cyanocobalamin.

The woman noticed that the color of the actual liquid was different, in addition to the cap on the bottle, but she dismissed her concerns as a potential change in manufacturer.

Then, as usual, the woman’s son came over to help her with the injections. After inspecting the bottle, he asked the woman about it. Fortunately, due to his prior medical training, her son realized that what the woman had was actually not the usual B12 vitamin injection, but rather the dangerous drug atropine, which is used to resuscitate patients in cardiac arrest, among other uses.

The woman had gotten the medication from the military base near her home in Virginia, which sends its prescriptions out to a national center to be filled. It was apparently the national pharmacy that made the error.

The medicine the woman was given could have killed her instantly, or at least led to a heart attack or stroke, among other side effects.