Articles Posted in Common Errors

Unfortunately, incorrect or erroneous distribution or application of medications is surprisingly present in the United States. In fact, some sources cite a rate of one in five Americans experiencing a medical error while receiving health treatment. Unfortunately, Maryland is no exception to this trend, and Maryland residents should be aware of emerging best practices in the face of the increased computerization of pharmacies and hospital medication cabinets.

Additionally, medication errors are among the most common medical errors, harming at least 1.5 million people every year. The extra medical costs of treating drug-related injuries occurring in hospitals alone are at least $3.5 billion a year, and this estimate does not take into account lost wages and productivity or additional healthcare costs, the report says. Medication error morbidity and mortality costs are estimated to run $77 billion dollars per year. Patient safety is a major public health concern.

What Are Medication Errors

When medication dispensing errors happen, they can cause serious side effects and life-altering issues for patients, and in some cases, these errors can lead to death. According to the National Institute of Health (NIH), each year in the United States, 7,000 to 9,000 people die as a result of a medication error, and hundreds of thousands of other patients experience but often do not report an adverse reaction. Medication errors can cause a lack of trust in the healthcare system generally and in healthcare providers. In addition, these errors have financial costs as well, with the NIH reporting that medication-associated errors exceed $40 billion each year.

According to a recent news report, a medication dispensing error in D.C. almost cost a 74-year-old woman her life. The patient had been recently released from the hospital and went to a rehab facility to recover from a blood clot. However, within weeks, the patient began complaining about swelling in her throat, prompting her family to look at what prescriptions the facility had given her. Her family members realized that the facility had dispensed the wrong medication, giving her drugs with someone else’s name on them. To make matters worse, the patient’s eldest daughter realized that the facility had given her a drug that her mother was severely allergic to. The patient was raced to the nearest emergency room just in time, as her throat was nearly swollen shut. She was put into a medically induced coma for more than a week.

When it comes to our prescriptions, we count on pharmacies to get it right. Instructions scribbled by doctors on notepads or hurriedly said by nurses and office staff while we check our calendars for follow up appointments or scrutinize our bills are hardly reliable. Instead, checking and double-checking pill bottles or printed pharmacy instructions before consuming prescription medication is often the safeguard patients use to ensure they’re not over or under consuming their prescribed drugs. When these instructions are wrong, the results can be catastrophic.

In this case, the error occurred because the verification by two pharmacists failed to catch the mistake. Some pharmacies do not have processes for typing directions, even though these medications should often be administered in a standardized way. Doctors provide varying instructions, and pharmacies often follow the doctors’ instructions verbatim or close to it, without verifying the units and dosage against standards for the medication. The prescription in question would have also been easier to understand had the pharmacist instructed the patient to inject one entire pen, rather than 1 milliliter or milligram, as the pen was designed to hold one dose. Pharmacies can also employ more checks to ensure patients understand how to use medications, like asking patients to repeat instructions back and confirm dosage.

Patients seeking medical care have certain standards and expectations for what they will receive when getting treatment. When those standards are not met, the consequences can be dire. For patients whose lives are on the line, one small mistake from a doctor, nurse, or pharmacist can have an enormous impact.

Recently, a woman picked up what she thought was cancer medication from her local pharmacy. She took the prescribed pills for two months before realizing that she had actually received anti-cholesterol medication from the pharmacy instead of the medicine she intended to be taking. The woman’s doctor had prescribed her a drug called exemestane, but the pharmacist had failed to check the medication bottle and had given her something called ezetimibe instead.

Apparently, the pharmacists providing the medication failed to properly dispense the prescription. The pharmacy was supposed to have a three-step process for ensuring that each patient’s medicine was what they were expecting to receive: a check when the medicine was selected from the shelf, a second check when the dispensing label was put on the container, and a third check when the prescription was given to the patient.