Common Errors

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.

Preventable Maryland Pharmacy Errors in Vaccine Administration

July 5, 2022 | Lebowitz & Mzhen

Following the Centers for Disease Control (“CDC”) endorsement of the Advisory Committee on Immunization Practices (“ACIP”) recommendation that children six months through 5 years should receive a COVID-19 vaccine, many people are flocking to their doctors and local pharmacies to obtain the vaccine. However, this news comes amid a significant pharmacy worker shortage. As such, in an attempt to avoid a Maryland pharmacy error lawsuit, many chains are reconsidering whether they will provide COVID-19 vaccinations to children under the age of 5.

For instance, recent news outlets reported that Publix would not offer coronavirus vaccines to children under 5 “at this time.” A spokesperson for the chain grocery and pharmacy store declined to elaborate on their decision; however, the website indicates that the store is continuing to accept appointments for children five and older.

Despite some retailers and pharmacies’ reluctance to vaccinate young children, many pharmacies can do so safely and effectively. However, given the current supply chain issues and worker shortages, pharmacies must take steps to prevent errors. When a pharmacy fails to do so, it may be liable for any ensuing damages or injuries.

Helping Maryland Medical Providers Avoid Pharmacy Errors

May 10, 2022 | Lebowitz & Mzhen

Anyone who takes prescription medication on a regular basis understands the importance of consistency and accuracy. Whether you pick up one or several medications on a regular basis at the pharmacy, every patient deserves to have peace of mind when they receive their prescription. After all, if a medication error were to take place, the consequences could result in injury, or in extreme cases, even death.

Improper dispensing of medications is more common than you may think—in fact, one in five Americans has experienced a medical error while receiving health care. The issue was given even greater attention more than four years ago, when a nurse typed two letters into a hospital’s computerized medication cabinet, selected the wrong drug from the results, and then administered a fatal dose to a patient. Because most hospital systems or pharmacies have computerized medicine cabinets, such technological vulnerability is not uncommon—and Maryland is no exception.

How can medication and pharmacy errors be prevented?

According to a recent news report, pharmaceutical safety experts are recommending a new method for medical practitioners to avoid pharmacy errors. With a new software update that requires drug names to be searched with five letters rather than three, experts are hoping that the fix will rectify issues surrounding withdrawing the incorrect drugs. Currently, most computerized medicine cabinet software programs require practitioners to type only three letters to search up a drug. For example, when a nurse types “M-E-T,” the search results could bring up anything from metronidazole to metformin. One of these drugs is an antibiotic—the other is for diabetes. Administering the wrong drug could yield disastrous results.

National Medication Errors Reporting Program Expands List of Potentially Dangerous Drugs

March 25, 2022 | Lebowitz & Mzhen

Prescription drug side effects and drug interactions may be minor and unnoticeable, though some drug effects can be severe, and even fatal. Doctors and pharmacists are responsible for the drugs they prescribe and dispense, and harmful side effects and drug interactions should be considered when giving a drug to a certain patient. Because some drugs are more prone to causing serious side effects and harmful interactions, a nonprofit organization known as the Institute for Safe Medical Practices (ISMP) has been compiling a database of the medications that carry an increased risk of resulting in patient harm when they are used or prescribed incorrectly. This database is part of the ISMP’s division known as the National Medication Errors Reporting Program (MERP). An article recently published by a pharmaceutical trade industry journal discusses some recent revisions that have been made to the ISMP database.

According to the recently published article, the medications in the database are not necessarily more likely to cause side effects or drug interactions, but the effects and interactions that do occur with the listed medications are more likely to be serious and result in patient harm. The article notes that the use of the MERP medication database is only a small part of an effective risk reduction strategy that should be employed by pharmacies to protect their patients. Medication errors will probably never be completely eliminated, and because of that, it is especially important for pharmacies and their employees to utilize a multi-faceted approach to preventing and catching medication errors.

What Is the Most Common Cause of Prescription Errors?

Human error is the most common cause of harmful medication mistakes. Because pharmacists and their employees are often overworked and understaffed, it is not prudent to place all of the responsibility for catching an error with a single person. The great advances in machine learning algorithms and automation technology have enabled pharmacies to automatically catch many errors that may have gone unnoticed before. Even with the technological advances, the ISMP recommendations are not always eagerly followed by pharmacies. Corporate greed, cost-cutting measures, and stubborn decision-makers who are resistant to change can all prevent improvements in the industry. When pharmacies refuse to listen to sound advice like that given by the ISMP, patients can be put at risk. Because of this, patients are still in danger of serious harm from medication errors anytime they visit a pharmacy.

Pharmacist Burnout Persists Two Years into the Pandemic

March 17, 2022 | Lebowitz & Mzhen

The Covid-19 pandemic has strained nearly every industry worldwide, however, healthcare workers remain one of the most affected groups by the public health crisis. Pharmacists in particular are especially burdened with extra duties related to vaccination and testing, as well as the staffing shortages and worker burnout that are affecting industries nationwide. Because pharmacists and pharmacy workers are so strained, the risks associated with burnout are real. Strained and stressed out pharmacists and other medical workers are more likely to make mistakes in their work, which may put patients at risk. A recently published news report discusses measures that one pharmacy chain is taking to address the risk of burnout among pharmacists and other employees.

According to the local news report, a major national pharmacy chain is enacting a new policy to close down their pharmacies for a 30-minute lunch break where every pharmacy employee will be given uninterrupted time to themselves to prevent the effects of burnout from affecting their work. According to company sources quoted in the news report, pharmacists and other employees have been complaining about unsustainable levels of stress and the lack of adequate breaks. The company hopes that the new policy will help their workers’ psychological wellbeing while also protecting patients from pharmacy errors.

Can Pharmacists Be Responsible for a Doctor's Prescription Error?

Yes, in some cases, pharmacists can be legally responsible for a mistake that originated with the prescribing physician. Pharmacists and their assistants play an important role in checking of the drugs that were prescribed by a medical provider to a patient are being dispensed properly. Doctors can make mistakes in choosing drugs or dosage amounts, and harmful drug interactions may not be noticed until it is too late. Because of this, it is important for pharmacy employees to be attentive and vigilant in protecting their patients.