Common Errors

Study Shows Barcode eMAR Technology Can Help Reduce Medication Errors

November 3, 2010 | Lebowitz & Mzhen

In a recent blog, our Maryland pharmacy error injury attorneys discussed reducing medication error and patient injury with barcode electronic systems, that link barcodes on the patient’s wrist bracelet with the patient’s electronic records and prescriptions, to ensure that the medication and dosage match the prescription for the patient.

According to a recent study that the Agency of Healthcare Research and Quality (AHRQ) in Rockville, Maryland, has funded, barcode technology, working together with eMAR, the electronic medication administration system, can help reduce medication errors by over 50%. The study was published earlier this year, in the May issue of the New England Journal of Medicine.

Barcode eMAR combines technology to ensure that each patient is given the proper medication with the correct dosage at the right time, in order to prevent medication errors or patient injury. When this combination of technology is used, before administering the medication, the nurses must scan the barcode on the patient’s wrist bracelet, and then scan the medication. If both barcodes don’t match the approved medication, or the timing is not correct for the patient’s next dose, an alert is issued by the system. If the patient’s medication is overdue, warnings are also sent out to the nurses.

In the study, researchers at Boston’s Brigham and Women’s Hospital compared 6,723 medication administrations given on hospital units before the barcode eMAR was introduced with the 7,318 administrations of medication given after the barcode system was introduced.

Children’s Hospital Launches Initiative to Prevent Medication Error

November 1, 2010 | Lebowitz & Mzhen

After two children died from medication errors at Seattle Children’s Hospital over a period of 18 months, as our Baltimore, Maryland medication error injury lawyers recently discussed in a blog, the staff of the hospital held a special ‘Zero Errors Initiative’ Patient Safety Day on Saturday, to prevent tragic medication errors like these from happening to children in the future.

According to the Seattle Post Intelligencer, over 550 physicians, staff, pharmacists, and nurses convened at the hospital for special patient safety sessions, focusing on training designed to prevent future incidents of medication and pharmacy errors.

Pat Hagan, the president of Children’s Hospital reportedly stated that these tragedies and the harm that was done to these children by the hospital will never be forgotten. Hagan said this has been a profound tragedy for the families, and for the hospital staff, and that this feeling will propel the hospital to continue to find ways to prevent life-threatening medication errors from happening.

The sessions during the safety training day included topics such as strengthening the safety of verbal orders, standardizing children’s medications located on care units, prescribing, dispensing and administering medications that are high-risk, improving communication between providers when handing off patients, and patient safety training with the use of simulation.

Pharmacy Error Gives Wrong Drug to Premature Babies

October 29, 2010 | Lebowitz & Mzhen

In a blog from earlier this year, our Washington D.C. pharmacy error injury attorneys discussed Dennis Quaid’s high profile lawsuits against Baxter Heathcare Corporation, that were filed after his newborn twins were given a near-fatal overdose of Heparin, a blood thinner. The medication error was allegedly due to a mistake with Baxter’s look-alike labels, and the twins were given 10,000 units of Heparin instead of 10 units of Hep-Lock, originally prescribed to treat a staph infection.

In a recent medication error in Saskatchewan, Canada, four premature infants in the neonatal intensive care unit at Royal University Hospital were prescribed the drug Heparin, the blood thinner used to prevent clots, and were mistakenly given insulin with the brand name Humulin R, and that was reported to have a similar looking label.

The pharmacy mistake was discovered because all infants were in the same unit, and their conditions were reportedly deteriorating in similar ways due to the insulin, which caused them to have dangerously low blood sugar levels. The infants mistakenly received the insulin in their IV infusion instead of Heparin.

In the review of the incident, the mistake was reported to be caused by an over crowded space in the pharmacy, a possible labeling error that was missed during the many safety checks, or an issue of look-alike labels.

Reporting Children’s Medication Errors Can Help in Prevention

October 1, 2010 | Lebowitz & Mzhen

A recent news article reports that medication errors are among the most common mistakes made by healthcare practitioners—and also among the most under reported.

In a tragic medication error from last year, a child at Seattle Children’s Hospital died from a medication error allegedly involving Calcium chloride. The hospital reported its mistakes to the health department and has acknowledged them publicly. Calcium chloride, the medication that reportedly caused the child’s death, is listed on the Institute for Safe Medication Practices’ (ISMP) class of pharmaceuticals as one of the institute’s “high-alert” medications.

According to the Agency for Healthcare Research and Quality (AHRQ), medical errors are one of the leading causes of death and injury in the U.S. The AHRQ reported in a recent study that rates for potential adverse drug events in hospitals were three times higher with children than adults, with an even higher rate for infants in intensive care units.

According to Dr. Allen Vaida, executive vice president of the Institute of Safe Medication Practices (ISMP), acknowledging medication errors and reporting them is the most important step toward prevention. Vaida claims that children are especially vulnerable to drug overdoses in hospitals because of calculation errors that can occur with medications. Nurses must administer the medication dosages according to a child’s body weight and other necessary factors, that can lead to medication mistakes. He claims that in situations like this, it is important to share information about the medication errors that do occur, as reporting them can prevent errors from happening in the future.

Medication Error Causes Death in Washington State Hospital

September 30, 2010 | Lebowitz & Mzhen

In recent news, our Baltimore, Maryland medication error attorneys have been following the story of a recent tragedy, resulting in the death of a patient who went to the hospital for outpatient shoulder surgery, and died shortly after, due to a medication error.

According to the Seattle Post-Intelligencer, Gary William Clezie went to Yakima Regional Medical & Cardiac Center in February 2009, for a simple outpatient arthroscopic shoulder surgery. A few hours after the surgery, Clezie reportedly suffered from brain damage, as a result of an alleged medication error, and died two days later, when his family agreed to remove the construction worker from life support.

After the surgery, Clezie received Dilaudid for his pain, a potent opioid drug for pain management. Clezie was given a device that allowed him to medicate as needed, by self-administering the drug. The doctor reportedly ordered that Clezie have a blood oxygen level monitoring device, that would alert the nursing staff if the oxygen in his blood dipped below a specific level—in which case the staff would alert the doctor, remove drug device from Clezie, and make sure that he was given oxygen.

But according to the Post-Intelligencer, Clezie’s blood-oxygen monitoring device was not attached to him, so when his blood oxygen level plummeted below the doctor’s defined level, his doctor was not notified, he was not removed from the drug device, and he was not given oxygen. Clezie stopped breathing and suffered severe brain damage from the error that led the misadministration of the pain medication.

Clezie’s family reportedly filed a complaint with the Department of Health’s licensing division and the Department of Health determined, as a result of the medication error, that there were grounds for a corrective action against Yakima. The Post Intelligencer claims that Clezie is one of thousands who suffer harm, personal injury, or even wrongful death from medical care in Washington hospitals every year.

DEA Fights Prescription Drug Errors and Abuse with National Take-Back Initiative

September 28, 2010 | Lebowitz & Mzhen

In recent pharmacy injury news, that our Baltimore, Maryland attorneys at Lebowitz and Mzhen Personal Injury Lawyers have been interested in, the U.S. Drug Enforcement Agency (DEA) recently held a nationwide prescription drug “take-back” day. The event was designed to curb health hazards and medication errors that can occur when people hold on to expired medications or throw away unwanted drugs.

According to the DEA, prescription drugs in home medicine cabinets are at great risk for misuse, abuse and theft, as reports show that a large majority of prescription medication errors and abuse come from the drug cabinets of friends and families. The initiative was also striving to combat drug abuse with kids, who are reportedly finding old unused drugs in homes, and bringing them to school, or parties to get high—resulting in tragic drug error injury.

Last week in a medication error in Washington State, nine teenagers were hospitalized after taking prescription medications that were found in homes and passed around at a school bus stop. The kids reportedly took painkillers and anti-depressants. In another case in Philadelphia, an 18-year old accidentally overdosed on a pain reliever medication found at home.

The DEA initiative set up around 4,000 “take-back” drop off sites across the country to encourage people to drop off drugs, where no questions were asked. People were encouraged to either remove the medication labels or to cross out personal information before dropping the drugs at the site.

Woman Sues Medical Center for Negligence Over Accidental Reuse of Syringe During Surgery

September 20, 2010 | Lebowitz & Mzhen

In a recent medical malpractice news story that our Washington D.C. medication error attorneys have been following, a patient at a medical center in Pittsburgh was reportedly administered anesthesia before surgery with the wrong syringe—a syringe that had been already used on another patient.

According to WXPI, patient Kimberlee Blocker was at Forbes Regional Hospital to undergo surgery, when the hospital reportedly gave her the wrong dosage of anesthesia, from a syringe that had previously been used on another patient. Blocker claims she was told after the surgery about the medication error, and that another patient’s syringe had accidentally been placed on her tray.

Blocker stated that after the medical mix-up occurred, she had to endure six tough months of hepatitis and HIV tests to determine if the alleged medical mistake with the wrong syringe had infected her with any diseases. She claims to have cried every time she took a test and was forced to wait two-weeks each time, for the results to come back.

Blocker claims that she could have easily died on that table as the medication that was mistakenly administered to her before the surgery was not prescribed for her. She is reportedly suing the hospital for negligence. Although Blocker’s HIV and hepatitis tests came back with negative results, she hopes that this lawsuit will help others from having to undergo this kind of treatment in the future.

Walgreen’s Pharmacy Error Sends Two-year-old Child to the Hospital

September 14, 2010 | Lebowitz & Mzhen

In a recent news story that our Baltimore, Maryland pharmacy error injury attorneys have been following, a two-year-old child was rushed to the hospital, after a prescription error was made at a Jersey City Walgreen’s pharmacy, while dispensing the boy’s allergy medication prescription.

According to the Jersey Journal, the father of the young boy reportedly went to the Walgreen’s Pharmacy to pick up the prescription for his son’s hydrocortisone prescription, to treat his allergies. The pharmacy gave the father the correct medication for his child, and in addition, the wrong prescription for 10mg of oxycodone, a powerful pain medication that had been filled for a patient who shared the same last name and first initial as the boy.

Crystal Williams, the boy’s mother, reportedly gave her two-year-old child one of the Oxycodone pills, and after ten minutes was alarmed when the child looked dangerously sleepy. Williams then realized the serious pharmacy error that had occurred, after reading the label on prescription bottle—discovering that her child had been given a drug with someone else’s name on it.

Upon discovering the pharmacy error, Williams dialed 911, and rushed her child to the hospital where doctors reportedly gave him shots to keep him alert. A few hours later he was transferred to an intensive care unit at a different hospital. According to Michael Curci, the pharmacy director for LibertyHealth, which operates the Medical Center where the boy was originally taken, an excessive amount of oxycodone can be life threatening, as it can cause respiratory depression and the inability to breathe.

Preventing Prescription Errors: Consumer Reports Health Poll Finds Patients Want More Drug Information

August 30, 2010 | Lebowitz & Mzhen

Our Baltimore, Maryland pharmacy error injury lawyers have been following the results of a recent Consumer Reports Health Poll, that found that 65 percent of most Americans feel that drug makers have too much influence on doctors, and that doctors are too quick to prescribe drugs instead of exploring other non-drug options to manage health conditions. The poll also found that as patients, many Americans have a strong desire to acquire more drug information and safety details to prevent prescription errors in the future.

The Consumer Reports Health Poll found that:

• 45 percent of Americans take at least one prescription drug per day on a regular basis, and on average, they take around four prescription drugs.
• 39 percent of American consumers cut costs on personal healthcare in ways that might be dangerous and could lead to personal injury, with 27 percent failing to comply with drug prescriptions. In an effort to save money, 38 percent of individuals under the age of 65 who don’t have prescription drug coverage, failed to even fill the prescription.
• 87 percent of Americans stated that understanding the safety of a prescription drug was very important, and 79 percent of individuals were concerned about dangerous drug interactions. 78 percent worried about drug side effects.

• 47 percent of Americans said they think that pharmaceutical companies sway doctors’ choice of drug administration for patients based on gifts, and 41 percent of people stated that they think doctors tend to prescribe newer drugs that are more expensive.

According to the Institute of Medicine, at least 1.5 million drug errors occur every year in this country—errors that are preventable. John Santa, M.D. M.P.H., and Consumer Reports Health Ratings Center director, claimed in the study that Americans who are taking multiple drugs considered drug safety and side effects to be a high priority. The poll found that safety information provided in the pharmacy, doctor’s office or hospitals is not always comprehensive enough to prevent medication mistakes or drug error, and needs to be addressed.

Promoting Electronic Prescribing in Physician Practices

August 3, 2010 | Lebowitz & Mzhen

As our attorneys from Lebowitz and Mzhen Personal Injury Lawyers discussed in a recent blog, although e-prescribing usage has increased in recent years, many local doctors claim that the current e-prescribing systems, although helpful for reducing medication errors, can lead to more mistakes in prescribing.

According to Todd Rowland, M.D. and director of medical informatics for Bloomington, Hospital in Indiana, although the majority of electronic health records systems offer electronic prescribing as an option, some still charge a fee to doctors who use the electronic transmissions for prescriptions. In some instances physicians can send the prescriptions by fax for free, but then get charged to send prescriptions electronically. He also said that physicians are on tight time schedules, and systems that are new require additional steps, that are often overlooked.

Rowland also claimed that right now, many e-prescribing systems have unnecessary drug interaction alerts that pop up while a doctor is prescribing. He claims that as doctors have time-sensitive practices, the e-prescribing should provide high quality information, that prevents medication error, but also fits into their practice, without slowing them down.

Last year, the Center for Medicare and Medicaid Services (CMS) promoted the switch to electronic prescribing by paying doctors a bonus for e-prescribing. By 2012, doctors who are not e-prescribing with be financially penalized by the federal government. As we reported in a recent blog, President Obama’s economic stimulus this year included over $19 billion for health information technology, to help doctors and hospitals pay for the cost of electronic medical records systems and to help improve the safety, quality and efficiency of healthcare.