Common Errors

Common Pharmacy Errors that May Affect You

March 19, 2013 | Lebowitz & Mzhen

Pharmacy and medication errors are not limited to similar looking pills getting mixed up. A recent article by a pharmacist discusses the value of having an independent verification process in place in order to prevent mix ups or misinterpretations.

For example, in one case an order for the drug “eribulin” was misinterpreted by a pharmacist and entered into the computer system as epirubicin, perhaps because of the similar spellings of the words. Fortunately in that case, a nurse discovered the error when she compared the prescription label with the original order, and as a result the patient did not receive the incorrect medication. Both of the drugs in that case are used in breast cancer treatment, which is another possible explanation for the pharmacist’s misinterpretation.

It is recommended that when the names of drugs are so similar, that hospitals and pharmacies have preventative measures in place to avoid look alike or sound alike mixups. For example, in the hospital where the mixup occurred, the hospital added additional terms to the names, and incorporated caps in the middle of the names to offset any potential misreadings. Additionally, an organization for drug safety has recommendations regarding how to list these medications to avoid other potential misreadings.

Check Your Pills Twice: Pharmacist Gives Woman Incorrect Pills

February 19, 2013 | Lebowitz & Mzhen

A Seattle woman suffering from multiple sclerosis, who also recently underwent hip surgery, went to her local pharmacy to have her prescriptions filled.

When the woman went to take her pills, she noticed that something was a bit off. She knew that thecapsule was supposed to be white and green and have the numbers “293” imprinted on it, with a 250 milligram dose of her medication. Instead,however, she saw that the pill was light green and dark green, and had the number “294,” indicating that it was in fact a 500 milligram pill. It was then that she realized she had been ingesting doublethe prescribed dose for at least two days.

While it turns out that the printing and information on the label for her prescription pill bottle was correct, apparently the pharmacist at the Rite Aid where her prescription was filled gave her the incorrect dose. In a statement the woman reiterated that her doctor prescribed her medications in order to accommodate her MS, and that the potential impact on her health due to the double dosing is currently unknown.

In a statement regarding the incident, a Rite Aid spokesman stated that their company has a seven point check for accuracy for each prescription before it leaves the pharmacy. The company is now investigating to see if that procedure was followed, and will potentially require retraining for its employees.

Contaminated Medicine Believed to Be Source of Nationwide Fungal Meningitis Outbreak

October 27, 2012 | Lebowitz & Mzhen

Lebowitz & Mzhen

October 27, 2012

Updated: October 27, 2012 1:49 pm

Doctor Groups Advocate for Limits on the Use of Painkillers for Anything Less than Severe Pain

August 16, 2012 | Lebowitz & Mzhen

Several groups of doctors and health care officials are calling on the U.S. Food and Drug Administration (FDA) to modify its guidelines for opioid painkiller prescriptions. The proposed changes would include restrictions on “off-label” uses, meaning uses not explicitly approved by the FDA, and limits on the amount of time a doctor may prescribe a painkiller for a patient. The purpose of the changes would be to counter a growing rate of abuse and addiction to the powerful drugs, which has recently resulted in multiple adverse reactions and medication errors.

Abuse of prescription drugs is now the “fastest growing drug problem” in the U.S., according to the Centers for Disease Control and Prevention (CDC). The CDC says that about 27,000 people died from accidental drug overdoses in the U.S. in 2007, and an increased use, and abuse, of prescription opioid painkillers is responsible for much of that total. The government has already attempted crackdowns on “pill mills” and pharmacies that, they allege, sell painkillers to addicts without medical necessity. This includes widespread investigations of drug wholesalers that move large volumes of painkillers and other controlled medications. The latest recommendations would impact how pharmaceutical companies label and market their drugs, in addition to how doctors prescribe them.

Electronic Prescriptions Help Doctors and Pharmacies Avoid Medication Errors, Prevent Fraud and Abuse

May 31, 2012 | Lebowitz & Mzhen

Handwritten prescription slips have always presented risks to patients. The risk of a pharmacist or pharmacy technician misreading a doctor’s handwriting, sometimes known as “chicken scratch” among pharmacists, leads to the risk of a misfilled prescription. This could involve the wrong dosage of a drug, or the wrong medicine entirely, with the consequences ranging from adverse side effects, worsening of a patient’s condition, or even death. New computerized systems for doctors and other medical professionals, however, join the ever-increasing number of electronic solutions to common human errors. These systems can help combat not only pharmacy errors, but also prescription fraud and prescription drug abuse.

Electronic prescriptions, or e-prescriptions (e-Rx), allow a doctor to write a prescription by submitting a request to a pharmacy online, rather than writing out the prescription on a prescription pad. A 2010 study mentioned by the New York Times, which examined handwritten prescriptions from doctors, physician assistants, and nurse practitioners in New York, found a thirty-seven percent error rate for handwritten prescriptions, not including legibility errors. The study found legibility errors in eighty-eight percent of the handwritten prescriptions. These errors can result in a patient receiving the wrong dosage or the wrong medication. They may also result in the pharmacy needing extra time to consult with the prescribing doctor or professional to sort the matter out, which could cause harm to a patient in urgent need of a particular medication.

Congress promoted the use of e-Rx in the 2009 Health Information Technology for Economic and Clinical Health Act (HITECH Act), passed as part of that year’s economic stimulus bill. The HITECH Act establishes certain acceptable uses for electronic medical records, giving regard to issues of patient privacy and the security of patients’ personally identifying information. It specifically names e-Rx as an approved use.

State Revokes Three Professionals’ Licenses to Prescribe Medication

December 20, 2011 | Lebowitz & Mzhen

The Delaware Secretary of State’s Office has suspended the Controlled Substance Registrations of two medical doctors and a nurse practitioner because of allegations that they overprescribed a number of controlled substances in unreasonable and excessive amounts. Complaints filed against the the three, who all worked in the pain management field, further allege that they disregarded evidence that some of the prescribed medications were being abused or even diverted. The suspension immediately halted their legal authority to write prescriptions. One physician and the nurse practitioner reportedly also surrendered their Drug Enforcement Agency (DEA) registrations to federal authorities. The doctors may face further disciplinary action beyond the Secretary of State’s investigation.

One of the physicians, Dr. Mohammed Niaz, worked with the nurse practitioner, Jean Binkley, as her supervisor. The Secretary of State alleges that Dr. Niaz wrote prescriptions for over 57,000 tablets of various controlled substances during the first seven months of 2011. This amount included 42,000 tablets of the Schedule II narcotic Oxycodone. Binkley is alleged to have separately written prescriptions for over 89,000 Oxycodone tablets.

The state further alleges that one patient, using prescriptions obtained from Niaz and Binkley, obtained 360 Oxycodone tablets and 90 tablets of Alprazolam within a two-week period earlier this year. This is considered an unreasonable amount for one person for such a brief period of time. Alprazolam is the generic name for the drug Xanax, a Schedule IV controlled substance used to treat anxiety, but also highly prone to abuse. Both types of drug can be highly addictive and dangerous if abused, and their distribution is strictly controlled. The state alleges that many of the drugs obtained through prescriptions written by Niaz and Binkley ended up in the hands of people who did not have a prescription and did not have guidance on how to use the drugs safely.

Dr. Patrick Titus allegedly wrote an even greater number of irregular prescriptions. One pharmacy’s records reportedly showed 3,941 prescriptions written by Dr. Titus between January and November 2011, accounting for almost 750,000 pills of seventeen Schedule II narcotic pain medications such as Oxycodone, Oxycontin, and Morphine.

The Secretary of State launched an investigation with the assistance of the Delaware Attorney General’s office and the Division of Professional Regulation. Delaware law empowers the Secretary of State to revoke a medical professional’s license to prescribe medicine if “continued registration would be inconsistent with the public interest.” The Secretary of State’s reasoning in this case seems to be that these three medical professionals have established a sufficiently questionable prescription history, and that they would constitute a threat to the public interest if allowed to continue writing prescriptions.

Reducing Medication Error Injury by Keeping Health Record Journals

August 30, 2011 | Lebowitz & Mzhen

Our Prince George’s County, Maryland pharmacy error lawyer blog recently reported on the important role communication plays between patients and their healthcare providers—in order to reduce the risk of medication errors or pharmacy misfills, and to promote the safe and effective use of drug therapy.

Every year, 1.5 million Americans experience medication-related injuries, according to a study by the Institute of Medicine. In order to prevent medication errors, the American Pharmacists Association (APhA) reports that it is important for patients to keep accurate health records with them when visiting the doctor and pharmacist, including current prescription medication lists detailing the dosage information along with all health conditions that the medication is treating.

Patient medication lists can reduce the risk of pharmacy misfills, incorrect dosages, medication duplication, allergy interaction, and any harmful side effects from potential dangerous drug interactions. The APhA also states that by keeping drug lists with them at all times, patients can prevent medical error by providing emergency staff and hospital pharmacists with important information that could saves lives in an emergency.

According to a recent Chicago Tribune article, doctors are now recommending that individuals turn the medication lists into a comprehensive health journal, to keep healthcare providers informed and to prevent medication error injury.

Report Finds Medication Errors in Chronic Drug Therapy After Seniors Leave Hospitals

August 29, 2011 | Lebowitz & Mzhen

According to a recent study discussed in the Journal of the American Medical Association (JAMA), that our Baltimore medication error lawyers have been following, hospitalized patients are more likely to have medication errors than non-hospitalized patients—when drugs used to treat chronic conditions are unintentionally discontinued in hospitals, especially if the patients are in a hospital’s intensive care unit.

The study reportedly showed that transitions in healthcare can increase a patient’s chances for medical errors that stem from inaccurate or incomplete communication between the hospital staff, the primary care physician, and the patient—causing an interruption or discontinuation of medications that aim to help treat patients’ chronic diseases on a long term basis.

According to the authors, the problem of medication errors and the unintentional discontinuation of drugs can happen during hospital stays, transfers and discharge. Treatment in intensive care units can also increase the risk of medication errors of omission as the healthcare providers are focused on emergency care and may engage in the practice of discontinuing a medication used for chronic illnesses during a time of critical illness.

The medication error study followed nearly 400,000 patients who were older than 65, and who had over one year of experience continuously taking one of the following five drug classes: respiratory inhalers, gastric acid suppressors, statins, anticoagulant or antiplatelet agents, and levothyroxine, used to treat the thyroid gland.

Medical Error Leaves Judge with Surgical Sponge in Body

August 25, 2011 | Lebowitz & Mzhen

Our Baltimore medication error injury blog recently reported that according to the Institute of Medicine, 1.5 million medication error injuries occur every year around the country that are preventable, and as many as 98,000 deaths due to medical errors.

When Nelson Bailey decided to have elective surgery for diverticulitis, a condition causing him abdominal discomfort, he was told that he would be out of the Good Samaritan Medical Center in around four days. What Bailey didn’t expect, according to a recent article in the Sun Sentinel, was that he would suffer from two different and equally serious medical errors at the hospital that would change his live completely.

Bailey, a Palm Beach County judge, underwent the intestinal surgery in October 2009, where the surgeon made a medical error by mistakenly leaving a surgical sponge inside Bailey’s body—that was reportedly as big as a washcloth, and was left to fester for five months.

When Bailey was recovering from surgery he then experienced a hospital pharmacy error, after the pharmacy prepared the incorrect medication. The doctor had reportedly ordered blood pressure lowering medication, but when the wrong medication was sent from the pharmacy, the nurse gave him the drug without double checking the drug label.

New Palm-Vein Scanning Technology Introduced to Reduce Medical Errors in Hospitals

August 22, 2011 | Lebowitz & Mzhen

Our Hartford County, Maryland pharmacy error injury attorneys have been following the latest healthcare technology introduced by New York University’s Langone Medical Center, in an effort to reduce the amount of time it takes to check patients in to the hospital, and to eliminate medical errors.

As our lawyers have discussed in a previous Maryland medication error injury blog, according the Institute of Medicine, there are 1.5 million medication error injuries every year that are preventable, and as many as 98,000 deaths due to medical errors.

The new biometric technology aimed to improve patient safety is made by Fujitsu, the technology services company, and works with the concept that like fingerprints, every patient has an individual and unique palm-vein configuration. The technology uses near-infrared waves to take an image of a patient’s palm veins, which the software then links to that patient’s medical records in about a minute. Other reported benefits of the technology is that a patient does not have to be conscious during the check-in process, and the system eliminates the need for a patient to fill out any forms, unless the patient’s insurance has changed since the last palm scan.

The hospital reportedly experiences around 1.7 million patient visits per year, and is in the process of converting as many patients as possible to the new palm scanning system, to prevent medical errors and patient injury. Since 250 scanners were installed in June, over 25,000 patients have received palm-vein scans that have been registered in the system. The palm scan does not appear in the patient’s medical records, and it is not stored as an image. After the palm is scanned, the image is converted into special numeric code.