Common Errors

ISMP—Prescribing Fentanyl Pain Medication for Short-Term Pain Be Deadly

January 25, 2011 | Lebowitz & Mzhen

In a recent blog, our Baltimore County pharmacy misfill attorneys discussed the prevalence of medication error cases resulting from the incorrect administration of the strong pain relieving medication Fentanyl, also called Duragesic—that if used erroneously can lead to a drug overdose and even wrongful death.

According to a recent article by Michael Cohen, president of the Institute for Safe Medication Practices, (ISMP), Fentanyl is around 100 times more powerful than morphine and for that reason should only be prescribed to people with chronic and long-term pain, like cancer patients, who are opiod-tolerant from already taking heavy prescription narcotics, or opioids, for one week or longer. As Cohen describes, Fentanyl is effective for three days, keeping patients with long-term pain from having to medicate repeatedly during the day.

As our Baltimore, Maryland medication error attorneys reported in a related blog, Fentanyl should only be used with patients who are opioid-tolerant because even the lowest strength Fentanyl patches have the ability to cause major side effects, like breathing difficulties, which can lead to wrongful death. According to the 2007 FDA warning, the Fentanyl patch should not be used with patients who are not opioid-tolerant.

Cohen explains that patients who are opioid tolerant and tolerant of other prescription pain medications have less of a chance of experiencing breathing difficulty when using a Fentanyl patch that is properly prescribed, as stopped breathing is often what kills patients in an overdose. According to Cohen, the big medication mistake currently being made by doctors is using Fentanyl to treat pain post-surgery pain, called acute postoperative pain, which should be treated by using other painkillers.

The ISMP has reportedly been receiving fatality reports since the drug has been introduced, but September of last year proved to be a devastating month for Fentanyl medication overdoses, as three tragic deaths occurred after patients were given Fentanyl by their doctors erroneously, with doses that were too high, at 50mcg/hour.

Pharmacy, Nursing Home Sued After Pharmacy Misfill Leads to Resident’s Death

January 7, 2011 | Lebowitz & Mzhen

In recent news that our Washington D.C. pharmacy error attorneys have been following, a nursing home was fined $12,000 last month, after a pharmacy misfill caused a nursing home resident to receive the incorrect medication for 18 days, leading to her wrongful death.

The Auburn Citizen reports that according to an investigation by the New York State Health Department in March and April of 2009, Geraldine Burke, a 94-year-old resident, was given tablets of a blood pressure medicine and diuretic by three different nurses in the Cayuga County Nursing Home, instead of the thyroid medication she had been prescribed.

The tragic medication error reportedly happened as a result of a pharmacy misfill, where a technician at HealthDirect, a separate division of Kinney Drugs that provides pharmacy services for more than 100 facilities, had filled and shipped the wrong medication for Burke. The two medications reportedly had similar looking names—methimazole and metolazone—a common medication mistake that plagues pharmacies in this country, as our lawyers have reported in a recent blog.

Neither the pharmacy or the nursing home recognized the mistake, and Burke was given 11 doses of Metolazone, the diuretic. The autopsy reportedly found that Burke died from heart issues, that were a result of kidney failure, worsened by the diuretic, along with other conditions. When the facility discovered the medication error after her death, they reported it to the Health Department, where they were fined $12,000. Burke’s family sued Cayuga County for negligence, and in turn Cayuga sued HealthDirect for their pharmacy misfill.

A Pharmacy’s Guide to Medication Therapy Management

January 6, 2011 | Lebowitz & Mzhen

In a recent blog, our pharmacy misfill error injury attorneys in Baltimore, Maryland discussed the importance of medication therapy management (MTM) check-ups with a pharmacist, to avoid medication error, pharmacy misfill, and potentially dangerous drug mix-ups that can lead to patient injury or even wrongful death.

The goal of an MTM is to get the maximum benefit from a patient’s prescription medication, and to have the opportunity to ask the pharmacist questions, as one would talk with their doctor, to avoid any medication error, possible side effects or problems with single or multiple medications.

People who reportedly benefit from consulting a pharmacist about medication management are:

• Patients taking medication for more than one chronic condition such as diabetes, depression, asthma, or high blood pressure.
• Patients who are taking one drug with potentially risky side effects, such as the blood thinner warfarin, or medication for seizures.

• Patients who have a hard time following a medication schedule, who forget to take their medicine, or skip them because they are experiencing side effects.

When attending an MTM, Family members or care givers are recommended to join the patient, and patients are advised to bring all medication with them, and if diabetic, their blood-glucose meter along as well. An MTM meeting is recommended once a year, unless the patient is prescribed a new medication and experiencing troubling side effects, a possible medication error, or if the patient is having monthly scheduled meetings the pharmacist.

Man Died from Overdose of Fentanyl—Widow Sues Center for Medication Error

January 4, 2011 | Lebowitz & Mzhen

Last year, our Baltimore medication error attorneys reported on two cases involving alleged overdoses of the powerful pain medication Fentanyl—one blog discussed a wrongful death lawsuit, where an 68-year-old died after allegedly receiving an incorrect dosage of the potent pain killer, and another blog discussed an overdose of duragesic pain patches, where a care center staff reportedly failed to follow the doctor’s prescription and wait 72 hours before increasing the pain dosage, which also led to a fatal overdose.

In recent news, the widow of a man from Illinois is suing a local pain treatment center for the wrongful death of her husband, due to a medication error of Fentanyl, administered through a SynchroMedII pump. According to Sue Daniels, her husband Tony was admitted in December 2009 to the Piasa Pain Center and was given an incorrect dosage of Fentanyl, which caused him to overdose from the medication error and led to his death. When Daniels became unresponsive from the overdose, he was transferred to Alton Memorial Hospital. Sue claims that the Fentanyl injections caused him to suffer from severe brain damage and lung injuries. He died two years later.

Sue Daniels accuses the pain center of negligence for administering the lethal dosage of pain medication, and blames the managers of the pain center for failure to properly train the medical staff on how to use the equipment. Alton hospital is also named in the suit for not treating Daniels fast enough after the overdose, and for running the Piasa Pain clinic that reportedly administered prescription drug error. Medtronic is also listed as a defendant for manufacturing a pain pump that is allegedly defective.

Sue Daniels is asking for over $500,000 in damages for medical bills, court costs, pain and suffering.

The opioid fentanyl is a narcotic used for patients who are opioid-tolerant from using another potent narcotic pain medication for a week or more. The opioid-tolerant patients are often prescribed Fentanyl when they need an even stronger narcotic for strong pain relief. Fentanyl is only recommended for patients who are opioid-tolerant, as even the lowest strength fentanyl patch has the ability to cause severe side effects, and even wrongful death, according to the FDA. The FDA does not recommend fentanyl patch usage with patients who are not opioid-tolerant—as the warning stated in 2007.

Medication Therapy Management and the Prevention of Medication Error

December 28, 2010 | Lebowitz & Mzhen

According to the American Pharmacists Association (APhA), medication-related events are a massive problem to this country’s public health and well being. As our Baltimore medication error injury attorneys have reported in a related blog, according to the APhA, 1.5 million people are injured by medication errors every year, that cost around $177 billion in personal injury and death, and could be preventable.

Ed Webb, associate executive director of the American College of Clinical Pharmacy, recently stated that prescribed medication is only beneficial if taken correctly, and if medication therapy is not managed well, it can do harm. Webb, along with other experts, recommends medication checkups, known in the business as medication therapy management, or MTM.

As our Baltimore pharmacy error attorneys also discussed recently in a blog, more and more people are being encouraged to make appointments with their pharmacists as well as their doctors to discuss the medications that they take in an effort to prevent medication error, pharmacy misfill or patient injury.

Patients reportedly often end up saving money when meeting with pharmacists, by switching prescriptions to generic drugs instead of brand-name, or dropping medications that they may no longer need. Other patients are often able to eliminate medication side effects with help from a pharmacist on the best time to take the medication, possibly changing to a different drug, or avoiding a potentially dangerous mix-up of drugs, which can lead to expensive trips to urgent care or emergency rooms and result in personal injury.

CVS Pharmacy Misfill Mixes up Child’s Hyperactivity Drug with Methadone

December 22, 2010 | Lebowitz & Mzhen

In recent news that our Baltimore pharmacy error attorneys have been following, a nine-year-old child in Las Vegas reportedly received an accidental pharmacy misfill at a local CVS Pharmacy, after his hyperactivity medication was filled with methadone, a drug frequently used to treat withdrawal and dependence problems with people who are addicted to Heroin.

Tammy Jordan claimed that her son, Kyren, an active kid, is sometimes prescribed the drug Methylphenidate, to help treat his hyperactivity disorder. Jordan claims that she didn’t even check after picking up the prescription from CVS, as this was a common medication for her son.

According to KTNV.com, Jordan reportedly noticed that after Kyren had been taking the prescription misfill for an entire month, he couldn’t sit still, and couldn’t tell his mother why. A few weeks later, after dropping off the medication at Kyren’s school, the nurse called Jordan, and was alarmed that Kyren was taking Methadone and not Methylphenidate—the medication that the nurse regularly gave to the child.

Jordan claims that she was shocked by the medication error, and stopped Kyren from taking any more of the drug. He reportedly went through a period of withdrawal, but made a full recovery with no injury. Once Kyren recovered, she reportedly approached CVS, where the pharmacist on duty took the bottle and peeled off the first label, revealing that another label had been mistakenly placed on top of Kyren’s medication.

The state Board of Pharmacy is reportedly looking into the prescription drug misfill, to decide what exactly what happened, and how to prevent prescription filling errors from happening in the future.

In a recent blog our Baltimore pharmacy error injury lawyers discussed tips for preventing pharmacy misfills when picking up your child’s prescription at the pharmacy, including verifying the medication, always double checking the name on the prescription, the dosage, usage, and whether the drug is suitable for your child’s weight and size.

Healthcare Center Sued for Wrongful Death After Man Dies from Pain Medication Overdose

December 1, 2010 | Lebowitz & Mzhen

In recent news that our Washington D.C. nursing home attorneys have been following, a medication error lawsuit has been filed against a local hospital in Salt Lake City, after a patient died from receiving an alleged overdose of a potent pain medication.

According to Deseret News, Clarence Burton was admitted to Woodland Care Center on August 1, 2008, to be supervised by nurses while he underwent radiation and chemotherapy treatment at St. Mark’s Hospital. Burton was reportedly fighting bone cancer, and had been prescribed the brand name pain medication patches Duragesic, containing the strong medication fentanyl to help him deal with the pain.

The lawsuit alleges that the care center staff members made a grave medication mistake when they failed to follow the doctor’s prescription, which was to give Burton one 50-milligram pain patch every 72 hours. The manufacturer of Duragesic also advises to wait 72 hours before increasing the pain medication dosage. Instead, the staff allegedly applied three pain medication patches on Burton’s neck, and he was found a few hours later, lying the floor in complete cardiac arrest.

When Woodland was met by the emergency personnel, they were reportedly unable to revive him, and he was taken to the hospital, where he was given another drug to counteract the fentanyl overdose. Burton was later resuscitated, but according to the lawsuit, remained unresponsive, as he had sustained sepsis, renal insufficiency, and elevated liver function as a result of the alleged malpractice. Burton was taken to another care center six days later, where he died on August 9, 2008.

Glaxo Pays $750M in Settlement for Violations in Pharmaceutical Drug Manufacturing

November 23, 2010 | Lebowitz & Mzhen

Our Washington D.C. pharmacy error injury attorneys have been following the recent announcement by the U.S. Department of Justice (DOJ) that GlaxoSmithKline (GSK), a research-based pharmaceutical and healthcare company, has agreed to pay the government $750 million in an effort to settle criminal and civil charges alleging that the company sold adulterated drug products to Medicaid and other government health plans, risking the health and safety of consumers.

Cheryl Eckard, a former Quality Assurance Manager for GSK, was reportedly assigned to visit the company’s Cidra, Puerto Rico plant in 2002 with a group of 100 experts and scientists to survey violations cited by the FDA in drug manufacturing. Eckard reportedly discovered major manufacturing and quality testing issues that went beyond the FDA violations, and that could have caused medication error or patient harm.

Deficiencies found in the plant include the release of a topical antibiotic Bacrtoban ointment used to treat skin infections on babies that contained microorganisms, and the production of the Kytril injection, used by cancer patients for nausea that was reportedly not sterile. Deficiencies were also found in the manufacturing of the antidepressant Paxil CR tablets, causing the drug to have the incorrect amounts of active ingredients. Another manufactured drug, Avandamet, a derivative of the drug Avandia, used to treat diabetes, were reportedly found to be superpotent and subpotent.

As the Cidra plant was reportedly GSK’s top manufacturing facility in the world at that time, bringing in $5.5 billion every year, Eckard found that GSK could not assure that they produced contamination-free products that were made in accordance to the drug formula registered with the FDA. She reportedly advised GSK managers to close the plant, and submitted an extensive report to the compliance department at GSK, who claimed her report was unsubstantiated.

Maryland Hospitals Decrease Medication Error with New Technology

November 18, 2010 | Lebowitz & Mzhen

According to a study that our Baltimore, Maryland attorneys reported on in a recent blog, thirty-five Maryland hospitals increased their median safety over the past ten years, reducing medication error and patient injury with new technology.

In Maryland’s Peninsula Regional Medical Center, the hospital is reportedly improving the tracking of patient records and the prevention of complications with drugs that can lead to medication errors, when medication is improperly administered, through technology. The hospital is reportedly using a barcode system that our Maryland medication error attorneys also discussed in a recent blog, that removes the chance for medication errors by using barcode scanners to ensure that the barcodes on the prescription match the patient’s bracelet wrist-band and the medication, as well as the dosage.

The hospital also uses “Rosie” the Pharmacy Robot, who joined the pharmacy in 1999 and fills 2,500 doses daily from the pharmacy with 100% accuracy. By using barcode technology, Rosie finds a patient’s drug that has been ordered by the physician and then entered by the pharmacist, and prepares the medication with a special barcode for patient delivery. The robot reportedly even notes when the medication stocks are running low and creates new orders electronically.

Other Maryland patient safety initiatives include the use of electronic medical records, Acudose Medication Storage Cabinets, where security codes are used and any drug taken from the cabinet is recorded, and Online Point of Care Wireless Patient Charting. The hospital is reportedly working on eliminating all human error, and continues to invest in new strategies and procedures as well as technology to reach “zero errors” to protect the health and safety of patients.

Study Finds Maryland Hospitals Improve Safety and Health Standards

November 17, 2010 | Lebowitz & Mzhen

A recent study, published in the medical journal, Quality & Safety in Health Care, reportedly found that thirty-five Maryland hospitals showed notable improvements in the safe delivery and administration of drugs to patients in hospitals.

The study was performed on behalf of the Maryland Patient Safety Center, whose aim is to create health care in Maryland that is safer than any other state in the country by reducing adverse medication events, improving patient safety, and by focusing on improving the care systems in Maryland hospitals.

Released in October of last year, the study concluded that when measuring the delivery of medication, the combined Maryland safety scores for these hospitals dealing with acute care rose by almost 10 percent in over two years, reducing occurrences of medication errors.

By comparing safety data on medication and drug use between the years of 2005 and 2007, the authors of the study reported that Maryland hospitals received the highest scores in the packaging of drugs, the standardized distribution of drugs and safe labeling, safe storage of drugs, and keeping chemicals that are hazardous away from drug-preparation and patient areas, to reduce patient injury or harm.