Common Errors

NCL Campaign to Improve Medication Adherence and Patient Safety

May 15, 2011 | Lebowitz & Mzhen

As our attorneys reported in a recent Rockville, Maryland pharmacy misfill blog post, according to the National Consumers League (NCL), around three out of four consumers in this country admit they don’t take their prescription drug medication as directed—causing an increase in medication error and injury that has a huge impact on patients and the healthcare industry.

To combat medication error, the NCL has launched a national multi-media medication adherence campaign this month with the Agency for Healthcare Research and Quality (AHRQ), that will aim to raise patient awareness on the importance of taking medication as directed.

According to the NCL, when consumers fail to take medications as instructed by their healthcare professionals, it creates a problem that impacts not only the patient, but the caregivers, employers, researchers, health care practitioners, and tax payers as well. Nonadherence to prescribed medications can also result in injury or death.

Research presented by the league shows that one in three prescriptions never get filled, with 1/3 and 2/3 of hospital admissions linked to medication errors that stem from poor drug adherence. The total cost for nonadherence leads to a reported $300 billion a year.

The campaign will strive to enhance patient safety and improve the healthcare system, encourage health practitioners to properly and effectively communicate the importance of prescription medication adherence to patients, and raise awareness of the problem through public education and a national campaign.

FDA Redesigns Pharmacy Packet Inserts to Avoid Medication Error Injury

May 9, 2011 | Lebowitz & Mzhen

According to a recent article in the Wall Street Journal, a new national initiative is underway to make prescription medications clearer, and to decrease the rise of medication error that lead to hospitalizations and emergency room visits from patients who take their medication incorrectly—which according to the National Community Pharmacists Association happens to three out of every four Americans.

The U.S. Food and Drug Administration (FDA) is reportedly planning to test a new one-page information sheet to replace the many leaflet inserts and medication guides that are widely used in retail pharmacy chains across the country. And the U.S. Pharmacopeial Convention, the organization responsible for setting quality standards that are enforced by the FDA for the strength, purity and quality of medicines, has also developed a new program to create national standards for prescription labels, which currently vary greatly from pharmacy to pharmacy. The national label standard would require clearer instructions on the medication dosage, the medication timing and clearly state the purpose of the medication—to reduce medication and pharmacy error injury.

Currently, in pharmacies across the country, consumers may receive three different forms of drug information and pamphlets with their prescription medication—drug package inserts that are written by the drug manufacturer with FDA approval, drug guides for specific classes of drugs and products that are required by the FDA, and third-party consumer medical information. And according to the WSJ, recent FDA studies have shown that the drug information offered to consumers does not provide reliable understanding with the people taking the drugs, and is often conflicting in instruction, or even inaccurate, which could lead to patient harm or injury.

According to a recent FDA risk-communication advisory panel, more than half of adults misread or misunderstand one or more of common drug prescription precautions or warnings. In one study, patients were found to better understand language on warning labels that was simple and specific, like “use only on your skin” as opposed to “for external use only.” For consumers with lower English literacy skills, picture icons were provided, like a sun with a black bar, with the phrase, “limit your time in the sun.”

Walgreens Pharmacy Misfill Leaves Toddler With Dangerous Drug

May 4, 2011 | Lebowitz & Mzhen

Our Baltimore medication error attorneys have been following a recent pharmacy misfill incident that reportedly sent a Colorado Springs mother into great shock—as she nearly gave her small child an epilepsy drug that had been accidentally given to her by the pharmacist at a local Walgreens.

According to KDRO News, Channel 13, Kathy DeRosa went to pick up her son’s Motrin flu medication from the Walgreen’s pharmacy. The prescription reportedly had her 2-year-old’s name on it, along with medication information about the drug. Upon returning home, DeRosa noticed that bottle was smaller than the usual Motrin that she previously received for her son, and after investigating the bottle, she realized that the drug give to him was Levetiracetam—a drug used for epilepsy. DeRosa immediately called the Walgreens pharmacy manager about the prescription error and they brought the correct medicine to the house, apologizing for the dangerous mistake.

Levetiracetam, the drug mistakenly given to DeRosa’s son, is reported to have many potential side effects including fever, hallucinations a drop in white blood count and breathing difficulty, and is not intended to be used for children under the age of four. DeRosa claims that had her son taken the medication he could be in the emergency room, as he has asthma.

According to DeRosa, this pharmacy misfill shows parents the importance of carefully reading the labels on their children’s prescription bottles before leaving the pharmacy, and to check for potential prescription error. Had it not been for the change in bottle shape, DeRosa said they could be in a very serious situation right now.

Children’s Hospitals Form Collective Effort on Patient Safety to Prevent Medication Errors

April 13, 2011 | Lebowitz & Mzhen

According to a recent article in Pharmacy Practice News that our Washington D.C. pharmacy error injury attorneys have been following, a group of children’s hospitals in Ohio have prevented around 3,600 adverse drug events and surgical site infections, along with saving over $5 million, during an 18-month program initiative that was launched in 2009.

The initiative, called “Solutions for Patient Safety,” was reportedly launched with support of the Cardinal Health Foundation, who gave 1.5 million, along with the shared motivation of children’s hospitals in an effort to work together to eliminate preventable injury or harm to children.

Before the initiative began, each children’s hospital in the state reportedly collected data on adverse drug events in a different way—making it very difficult to compare or share information within hospitals. After conducting audits of a random collection of charts, the group was able to come together and manually identify and review the root cause of adverse events, and pinpoint a set of common concerns.

The initiative found that the main collective medication error problem was constipation from opioids, as well as over sedation as a result of the narcotics. Although constipation is not a life-threatening adverse drug event, it can reportedly add to more time in the hospital, more lab work, and tests, which can all add to additional costs.

Benefits of Robo Pharmacy Technology in Reducing Prescription Errors

April 1, 2011 | Lebowitz & Mzhen

In a recent Maryland pharmacy error injury lawyer blog entry, our attorneys discussed automated hospital pharmacies the use robots instead of people for tasks that are traditionally manual—in an effort to eliminate medication errors that could cause patient harm or personal injury.

According to the Medical Center of the University of California, San Francisco (UCSF), a hospital that recently implemented an automated hospital pharmacy–the benefits of using an robots instead of people are:

• Robots will help take over the manual medication dispensing tasks traditionally performed by pharmacists and nurses, who will in turn have more time to work with physicians to decide what the best patient drug therapy is, and will have more time to monitor each patient for any clinical responses or adverse reactions to medicine.
• The new pharmacy will provide pharmacy students with a strong training ground in the safe medication distribution systems of the future.
• The pharmacy will also enable the center to study new forms of medication delivery in order to share this groundbreaking information with other hospitals all over the country.

• Out of the 350,000 doses prepared by the robo-pharmacy since 2010, there has not been a single medication error or pharmacy misfill.

According to UCSF, the automated medication dispensing system will allow pharmacists to use their expertise in pharmaceutical care to make sure that each patients receives medication therapy that is catered to their individual needs, in a safe and effective way.

UCSF Employs New Automated Pharmacy to Prevent Pharmacy Error

March 28, 2011 | Lebowitz & Mzhen

In an effort to reduce pharmacy misfills and medication error, the Medical Center of the University of California, San Francisco (UCSF), has recently employed a series of pharmacy robots, according to recent technology news that our Baltimore-based pharmacy misfill attorneys have been following.

In the newly automated hospital pharmacy, UCSF has employed what they consider to be the most comprehensive robots on the market, to prepare and track medications and improve the safety of patients. According to UCSF, since the automated system took over in October 2010, there has not been a single error in the 350,000 medication doses prepared.

This newly automated pharmacy reportedly streamlines the delivery of medication from the prescription directly to the patient, making every step in the medication therapy process safe and effective–from deciding the best drug treatment to patient administration—in order to reduce medication error injury.

How the Robo-Pharmacy Technology works:

• The automated system reportedly prepares medications that are oral and injectable, including chemotherapy drugs that are toxic. The robots are also able to fill IV bags or syringes with medications.
• Once the computers receive a new electronic medication order from an UCSF physician and pharmacist, the robots pick the medication, package the drugs, and dispense doses of the pills that are individualized for each patient.
• The robots assemble medication doses into a thin plastic ring that contains a bar code with all of patients’ medications for a period of 12 hours.
• In the fall of this year, all UCSF Medical Center nurses will start using bar code scanners that read patients’ medication data at their bedsides–a topic our attorneys have discussed in a recent Maryland pharmacy error injury blog–to verify that the patient is being treated with the correct medication.
• A robotic inventory management system also maintains all medication products, with pharmacy warehouses that provide both refrigerated and non-refrigerated drug and supply storage and retrieval.

500 Unapproved Prescription Cough and Cold Medications Banned by FDA

March 22, 2011 | Lebowitz & Mzhen

Our Maryland-based prescription drug error attorneys have been following the U.S. Food and Drug Administration’s recent announcement, ordering the makers of around 500 prescription cold, cough and allergy medications to take the drugs off the pharmacy shelves, as they have not been proven to be safe and effective.

According to the FDA, the prescription drugs in question have not been linked to any major problems or drug-related injuries, but the FDA is still concerned that the medical problems associated with the drugs could be seriously under reported.

The agency claims that the drugs have not been evaluated by the FDA, and taking them may be more of a risk to the consumer than taking over-the-counter (OTC) medications to treat the same symptoms, that have been approved. The FDA also claimed that the action is necessary to protect consumers from any health and safety risks posed by these unapproved drugs, as the agency does not know how they are made, whether they are effective, or what is in them.

One of the problems that the agency found was with time-release drugs, which are reportedly hard to manufacture, and can release too slowly or not at all if quality controls in the manufacturing of the drug are inadequate. The FDA also made a move against unapproved products that contain drug combinations that could be considered dangerous, like combining two antihistamines, which could react in oversedation.

Hospital Sued for Wrongful Death After Patient Dies from Drug Error

March 22, 2011 | Lebowitz & Mzhen

Our Baltimore-based pharmacy error injury attorneys have been following the recent and tragic news story surrounding a Massachusetts woman, who endured a hospital medication error during a routine hospital stay that reportedly led to her wrongful death.

According to the Boston Globe, Geraldine Oswald was hospitalized in November of last year to clear up an infection that had developed after breaking her shoulder. While staying in the hospital, she reportedly received too much Lepirudin, a blood-thinning drug used to prevent the formation of potentially dangerous blood clots. The medication overdose affected Oswald’s own blood clotting ability, leading to internal bleeding. While in the hospital’s care, Oswald reportedly hemorrhaged for 12 hours before her wrongful death—which the hospital later stated could have been preventable.

The family of Oswald recently stated that they plan to file a wrongful death lawsuit against Massachusetts General Hospital, two nurses and five doctors, claiming that Oswald was supposed to be treated for a common infection, and instead received a blood thinner that was 30 times too high in dosage, and proved to be lethal.

According to the hospital’s report, the on-duty nurse understood the dosage intended for Oswald, but made a medication error while administrating the dose into the I.V. pump. In a meeting with Oswald’s family members after her death, the hospital reportedly stated that the medical error was preventable.

Pharmacy Misfill and Medication Error Prevention

March 8, 2011 | Lebowitz & Mzhen

In a recent Baltimore pharmacy error injury blog, our attorneys discussed the prevalence of pharmacy misfills and prescription drug errors plaguing our nation, with over 1.5 million injuries medication-related events documented by an Institute of Medicine study.

According to a related study discussed by Good Housekeeping magazine, pharmacy errors occur in one out of every five prescriptions. Another study reportedly found that 18 percent of hospital patients are exposed to medication errors. When addressing the problem of pharmacy error and medication mistakes, it is important for the consumer to always check and make sure that the prescription given at the pharmacy is the exact medication prescribed by the doctor.

As our Maryland medication mistake lawyers discussed previously, taking the necessary steps to verify your prescription with the pharmacist before taking medication can prove to be an extremely valuable step in preventing medication error injury. A few pharmacy error prevention tips include:

When receiving a new prescription, always ask the doctor to write down the medical problem associated with the medication, as this could help prevent a pharmacy misfill. Also, when filling a prescription for the first time, it is important to check the prescription label carefully to verify the name, dosage and directions for usage. It is also important to form a relationship with the pharmacist, to discuss the medication directions, as well as any potential allergies or potential medication conflicts that could happen with any other current prescriptions or supplements.

Another Child Receives Prescription Mix-up From Same Walgreens Pharmacy

February 23, 2011 | Lebowitz & Mzhen

According to news from the Jersey Journal that our Baltimore, Maryland medication mistake attorneys have been following, a local Walgreens Pharmacy has made another pharmacy error, the second in six months, by erroneously filling an 18-month old child’s acetaminophen elixir medication, similar to Tylenol, with an acetaminophen product containing codeine, a powerful pain reliever.

After unknowingly giving her child a pharmacy misfill for a week, Jannette Jackson reportedly became alarmed when her daughter seemed groggy and tired and was not improving with the medication.

Jackson then discovered the pharmacy error and confronted Walgreens, who admitted the prescription mistake. Jackson claims that her pediatrician was shocked to hear of the error, and stated that luckily the codeine dosage was not lethal, and did not cause any allergic reaction or personal injury to the child.

In the previous medication error six months ago by same Walgreens Pharmacy, that our attorneys reported on in a related Baltimore prescription error blog, a two-year-old boy was prescribed a hydrocortisone prescription to treat his allergies. The pharmacy mistakenly gave the child an incorrect prescription for 10mg of oxycodone, a powerful pain medication that had been filled for another patient. The two-year-old child was reportedly given one of the Oxycodone pills, upon which the pharmacy error was discovered and the child was rushed to the hospital.