Common Errors

Medication Dispensing Error in Maryland Leads Patient into a Coma

March 31, 2023 | Lebowitz & Mzhen

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.

Why Do Medication Dispensing Errors Happen?

Medication dispensing errors can occur for a variety of reasons, including human errors or issues with protocols that fail to prevent mistakes from happening. These reasons may include illegible handwriting, confusion over similarly named drugs or packaging, or errors involving dosing units, amongst many other reasons. In addition, if protocols and systems are not properly and effectively put in place to require that medical providers have a backup system to detect mistakes, then this can also lead to more pharmacy errors that could have possibly been avoided.

Using Digital Solutions to Prevent Medication Error

January 21, 2023 | Lebowitz & Mzhen

Medication error has been a leading cause of harm for patients, and an expensive cost for healthcare providers. In a digital age, some healthcare providers have implemented digital solutions to medication errors, but these digital solutions can cause doctors to receive too many alerts that lack specificity and that also cause alert fatigue for doctors. However, when science and technology combine to create a unified and efficient approach for drug administration and managing clinical decisions, it can be life-altering. A Healthcare IT News article details the importance of hospitals integrating precision medicine with digital maturity models. The digital maturity models can help technology advances that support clinical decisions. This can help prevent errors and increase efficiency, which thus can save lives and costs for hospitals. Giving users access to a single information source in a unified approach can help with drug administration and minimize alerts.

What Is a Digital Maturity Model?

Some examples of digital maturity models include from Wolters Kluwer, which built Medi-Span Clinical APIs drug data solution and expert services which helps ensure that accurate information is available at key moments rather than reported after the event, and also ensures the precision of alerts. Another example is the National Chen Kung University Hospital in Taiwan, which has used Medi-Span Clinical APIs to overcome challenges faced by pharmacists, including the challenge of the amount of time it takes to update a medication database. Medi-Span’s databases are updated regularly with best practice evidence and recommendations. Clinical APIs are for healthcare professionals only, and there are certain regulations that guide their use in various locations.

The hospital’s data shows that since implementing Medi-Span, the number of alerts has been reduced by 21% and the talerts have captured severe potential Adverse Drug Events. This resulted in saving approximately $39,200 in U.S. dollars a year, and also saved an estimated 266 bed days a year. Technology advances can allow for solutions that help prevent medication errors and help ensure that patients receive the best and safest care possible. When these errors occur but can be avoided by digital maturity, it is up to hospitals to implement unified approaches to avoid such costs.

Watch Out For Pharmacy Errors – They Can Be Fatal

November 30, 2022 | Lebowitz & Mzhen

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.

What Are the Potential Harms of a Medicine Dosing Error?

According to a recent report, a prescription for alirocumab, a drug to prevent cardiovascular events, was marked with erroneous directions. The pharmacy instructed the patient to inject “1 mg,” or one milligram, under the skin every 2 weeks. But the actual instructions were supposed to be injection of one milliliter. The instructed dosage would have been confusing and impossible to measure for a patient. While this error was fortunately realized by the patient due to the difficulty in measuring one milligram, other such errors—like transcribing a number incorrectly—could result in over or under-consumption of medications, which can lead to overdose or prolonged illness.

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.

Woman Receives Wrong Vaccine in COVID Booster Error

November 17, 2022 | Lebowitz & Mzhen

After a long period of lockdown, demand for COVID vaccines and boosters has been high. At times, the demand has exceeded both the supply of vaccines and pharmacies’ capacity to administer them. Unfortunately, when a pharmacy accepts a high volume of patients without increasing its capacity and hiring more staff, it can result in errors and mix-ups. These errors in vaccine administration have the potential to be fatal.

As a recent news article reported, a woman received the incorrect COVID vaccine booster at a Walgreens pharmacy in Rutland, Vermont. The woman received the vaccine after making an appointment for the “newest, most updated” COVID booster. Two days after her appointment, she received a call from the pharmacy informing her they had mistakenly administered an older version of the booster. The pharmacy employee told her she was still protected from COVID; however, the booster would not protect her from the newest strain. Luckily, the woman did not suffer any medical issues from the mix-up. However, given the potential for a more dire mistake, she filed a complaint with Walgreens’ corporate offices. After doing so, she claims she received an indication that other people had also received the wrong vaccine, though Walgreens denies that it happened to anyone else at the Rutland location.

Notably, the Vermont Office of Professional Regulation filed a complaint in June 2022 seeking to revoke or otherwise discipline the licenses of 32 Walgreens stores in the state, including the Rutland pharmacy. In fact, in its complaint, the Office reported that unsafe conditions at the pharmacies have increased the risk of prescription errors, vaccine administration mistakes, and the risk of harm to patients. Allegedly, Walgreens’s vaccine scheduling site had allowed such high volumes of appointments that staff could not keep up with the demand. According to the complaint, these issues resulted in the pharmacy’s inability to safely administer vaccines.

Woman Seeking Cancer Medicine Receives Anti-Cholesterol Medicine from Local Pharmacy in Potentially Devastating Mix-Up

October 27, 2022 | Lebowitz & Mzhen

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.

Covid-19 Vaccine Administration Errors Involving Labeling

October 14, 2022 | Lebowitz & Mzhen

After almost two years since COVID-19 vaccines become available, there are still concerns regarding avoidable administration errors that result from labeling and communication errors. When we walk into a doctor’s office to receive vaccines, we trust that we will receive the correct vaccination. But when administration errors occur for various reasons, it is important that these errors are accurately reported and that steps are taken to prevent these administration errors from happening again.

According to a recent news report, one current problem involves the labeling of the Moderna vials for the primary series for ages 6 to 11 years of age, which are still labeled as “for booster doses only.” Despite the label, these are not used for booster doses. In addition, there are two different Moderna vaccine vials that have a similar dark blue cap, which could result in an error if the vaccines are stored close together. The labeling includes the word “bivalent”, which may be more difficult to see on the Pfizer booster dose for ages 12 years and up, while compared to the Moderna label which may feature the word “bivalent” more clearly on the label. The word “bivalent” is essential to distinguish between the monovalent vaccine.

According to an interview involving the president of the Institute for Safe Medication Practices (ISMP), which was shared by Pharmacy Practice News, ISMP has received messages via Linkedin, phone, and email regarding how the labels appear to be so similar and regarding the difficulty of seeing the word “bivalent.”

New Best Practices Released for Ensuring Medication Safety

September 29, 2022 | Lebowitz & Mzhen

People that regularly take prescription medicine or have received prescription medication in a hospital or clinic setting can appreciate the vital importance of best practices when it comes to receiving medicine. Whether it is at the pharmacy or in the hospital, it is essential to be aware of safety measures that could make a major difference in the care you receive. Every patient deserves peace of mind when it comes to their medications, and to live free of the consequences of medical and pharmaceutical malpractice.

How Common Are Medication Mistakes?

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.

Emerging Best Practices to Reduce Harm

Study Reveals What Happens in Drug Administration Incidents Involving Wrong-Patient Errors

September 10, 2022 | Lebowitz & Mzhen

The process of receiving medication involves a lot of different moving pieces, and as providers complete their various tasks so that a patient may receive their proper medication, medication errors unfortunately can happen at any stage. Medication errors can involve errors in various stages of the process of ordering or delivering medication. For patients who are medically in need of specific medication to help their condition, and for patients who aren’t necessarily in dire need of their medication, but find themselves on the receiving end of a medication error, the consequences can be devastating.

What Can Happen After a Medication Error?

Medication errors can lead to serious injuries and can lead to adverse reactions. Medication errors can range from receiving the wrong dose, the wrong frequency, and the wrong drug, in addition to the wrong-patient medication error. However, when an incident report is filed and labeled as a wrong-patient error in medication administration, what exactly does that entail? It has been particularly unclear if wrong-patient errors for drug administration involves the wrong-patient receiving a medication intended for someone else, or if the intended patient received the wrong drug. A recent and eye-opening study sought to clarify the meaning behind “wrong-patient” errors in drug administration.

A study was recently published in August 2022 on DovePress, which features peer-reviewed journals in science, technology, and medicine. In this study, researchers investigated wrong-patient medication errors in incident reports that were voluntarily reported by medical staff at a university hospital in Japan. Specifically, the study investigated whether the patient or the drug had been incorrectly chosen in drug administration in incident reports that included wrong-patient errors. The results revealed a few things. First, the study included a total of 4,337 incidents that were reported between April 2015 and March 2016 at a particular hospital in Japan, and medication-related incidents were the most prevalent. According to the study, “[o]f the medication-related incidents, the largest number of incidents occurred at the medication administration stage…”. Evaluators determined “that cases where the intended drugs were administered to incorrect patients occurred less frequently than cases where the wrong drugs were administered to the intended patients.” In essence, this means that the study found that there were more mix-ups involving patients who received a different medication than what they were supposed to receive because there was some kind of mix-up with the type of medication administered (the patients were receiving the wrong drugs, versus situations where the right drugs mistakenly go to the wrong patient).

Improper Prescriptions and Optimization of Medications

July 31, 2022 | Lebowitz & Mzhen

Medication is by far the most common method for the treatment of diseases, with between 75% to 80% of physician office and hospital outpatient clinic visits involving medication therapy. Annually, about 275,000 people die each year, and roughly $528 billion in medicine is wasted due to poorly managed medications. Doctors, pharmacists, and other health care professionals have a responsibility to protect patients and ensure that every prescription is safe, effective, and appropriate for each patient. A recent article in the Pharmacy Times, authored by the executive director of The Get the Medications Right Institute, highlights some of the major barriers to appropriate prescriptions. Issues range from a lack of transparency to inadequate commitment to team-based care and benefit plan design integration by care providers. These problems can compound, ultimately resulting in dangerous results for patients.

According to the article, one of the consistent themes when it comes to the failure of medical professionals to optimize medications or prescribe the proper medicine is the current siloed approach to treatment. With different treatment providers unable or unwilling to communicate with each other in the current health care environment, cost-saving and comprehensive care are significantly more difficult to achieve.

What Are Steps to Prevent Improper Prescriptions?

The piece outlines five straightforward questions that health care providers, patients, and pharmacists can utilize to prevent improper prescriptions and optimize the impact of medication when it comes to health care. Briefly stated, the steps are to ensure the correct medication, allow patients to ask questions, ensure the proper dose, provide patients with a timeline for taking the medication and explain how patients will know the medication is working.

Pharmacy Errors and Covid-19 Antiviral Drugs

July 10, 2022 | Lebowitz & Mzhen

As the medical industry progresses and new treatments are developed to address novel health concerns, pharmacists and pharmacy employees have a responsibility to keep up to date on the safe practices for dispensing the medications that have been prescribed. With the advent of new antiviral treatments for Covid-19 infection, pharmacy errors have unfortunately occurred. The Institute for Safe Medication Practices, a professional organization for the pharmaceutical industry, recently released a report on the misadministration of an antiviral cocktail that had been effective at battling Covid-19 infection.

According to the industry journal, the antiviral medication cocktail marketed as Paxlovid has shown promise at treating Covid-19 infection, however dispensing mistakes have been noticed at pharmacies nationwide. The largest single issue with the administration of the drug appears when it is being administered to patients with kidney disease. If a patient exhibited moderate kidney disease and was prescribed the drug, a pharmacist was supposed to remove some of the pills from the blister pack to avoid damaging the patient’s kidneys, however, this was not always done. Patients with severe kidney disease should not have been prescribed the drug at all.

What Are the Common Causes of Prescription Errors?

A mixture of poor package design, unclear instructions, and pharmacist negligence has resulted in patients receiving the wrong dosage of the medication, potentially causing harm. According to the report, some patients received their prescription with the wrong pills removed, while others were prescribed the medication while suffering from advanced kidney disease, putting them at serious risk. Although the article does not mention any serious negative patient outcomes as a result of these errors, mistakes like these can be fatal in some instances. When dispensing a new medication that a patient has not taken before, a pharmacy employee has a responsibility to confirm that the patient understands the correct dosage and method of administration before sending them home with a bottle of pills.