Errors in local pharmacies

UCSF Employs New Automated Pharmacy to Prevent Pharmacy Error

March 28, 2011 | Lebowitz & Mzhen

In an effort to reduce pharmacy misfills and medication error, the Medical Center of the University of California, San Francisco (UCSF), has recently employed a series of pharmacy robots, according to recent technology news that our Baltimore-based pharmacy misfill attorneys have been following.

In the newly automated hospital pharmacy, UCSF has employed what they consider to be the most comprehensive robots on the market, to prepare and track medications and improve the safety of patients. According to UCSF, since the automated system took over in October 2010, there has not been a single error in the 350,000 medication doses prepared.

This newly automated pharmacy reportedly streamlines the delivery of medication from the prescription directly to the patient, making every step in the medication therapy process safe and effective–from deciding the best drug treatment to patient administration—in order to reduce medication error injury.

How the Robo-Pharmacy Technology works:

• The automated system reportedly prepares medications that are oral and injectable, including chemotherapy drugs that are toxic. The robots are also able to fill IV bags or syringes with medications.
• Once the computers receive a new electronic medication order from an UCSF physician and pharmacist, the robots pick the medication, package the drugs, and dispense doses of the pills that are individualized for each patient.
• The robots assemble medication doses into a thin plastic ring that contains a bar code with all of patients’ medications for a period of 12 hours.
• In the fall of this year, all UCSF Medical Center nurses will start using bar code scanners that read patients’ medication data at their bedsides–a topic our attorneys have discussed in a recent Maryland pharmacy error injury blog–to verify that the patient is being treated with the correct medication.
• A robotic inventory management system also maintains all medication products, with pharmacy warehouses that provide both refrigerated and non-refrigerated drug and supply storage and retrieval.

Pharmacy Misfill and Medication Error Prevention

March 8, 2011 | Lebowitz & Mzhen

In a recent Baltimore pharmacy error injury blog, our attorneys discussed the prevalence of pharmacy misfills and prescription drug errors plaguing our nation, with over 1.5 million injuries medication-related events documented by an Institute of Medicine study.

According to a related study discussed by Good Housekeeping magazine, pharmacy errors occur in one out of every five prescriptions. Another study reportedly found that 18 percent of hospital patients are exposed to medication errors. When addressing the problem of pharmacy error and medication mistakes, it is important for the consumer to always check and make sure that the prescription given at the pharmacy is the exact medication prescribed by the doctor.

As our Maryland medication mistake lawyers discussed previously, taking the necessary steps to verify your prescription with the pharmacist before taking medication can prove to be an extremely valuable step in preventing medication error injury. A few pharmacy error prevention tips include:

When receiving a new prescription, always ask the doctor to write down the medical problem associated with the medication, as this could help prevent a pharmacy misfill. Also, when filling a prescription for the first time, it is important to check the prescription label carefully to verify the name, dosage and directions for usage. It is also important to form a relationship with the pharmacist, to discuss the medication directions, as well as any potential allergies or potential medication conflicts that could happen with any other current prescriptions or supplements.

Another Child Receives Prescription Mix-up From Same Walgreens Pharmacy

February 23, 2011 | Lebowitz & Mzhen

According to news from the Jersey Journal that our Baltimore, Maryland medication mistake attorneys have been following, a local Walgreens Pharmacy has made another pharmacy error, the second in six months, by erroneously filling an 18-month old child’s acetaminophen elixir medication, similar to Tylenol, with an acetaminophen product containing codeine, a powerful pain reliever.

After unknowingly giving her child a pharmacy misfill for a week, Jannette Jackson reportedly became alarmed when her daughter seemed groggy and tired and was not improving with the medication.

Jackson then discovered the pharmacy error and confronted Walgreens, who admitted the prescription mistake. Jackson claims that her pediatrician was shocked to hear of the error, and stated that luckily the codeine dosage was not lethal, and did not cause any allergic reaction or personal injury to the child.

In the previous medication error six months ago by same Walgreens Pharmacy, that our attorneys reported on in a related Baltimore prescription error blog, a two-year-old boy was prescribed a hydrocortisone prescription to treat his allergies. The pharmacy mistakenly gave the child an incorrect prescription for 10mg of oxycodone, a powerful pain medication that had been filled for another patient. The two-year-old child was reportedly given one of the Oxycodone pills, upon which the pharmacy error was discovered and the child was rushed to the hospital.

Study Finds Frequency of Pain Relieving Medication Errors in Hospitals

February 9, 2011 | Lebowitz & Mzhen

According to a recent study in The Journal of Pain, that our prescription error attorneys based in Rockland, Maryland have been following, medication errors involving pain relievers, or analgesics, including errors made in prescribing, are a substantial contributor to adverse patient events in pain therapy that are preventable.

The study was performed in a hospital facility with 631 beds, and found that the frequency of pain medication errors in hospitals to be 3 per 1,000 prescriptions.

Researchers at the Albany Medical Center in the state of New York reportedly found in previous research that a major number of prescription analgesic errors are preventable, occurring in all stages of the prescription medication usage process, with the primary cause being prescribing errors. The researchers then combed through a large database containing prescribing errors that had been previously prevented by pharmacists in order to pinpoint the main characteristics associated with an increased risk for medication errors.

The overall drug error rate in the study was found to be 2.87 errors per 1,000 orders with a drug prescribing error rate of .63 per 1000 that was potentially serious. Error rates with analgesics were reportedly found to be higher in pediatric orders, a topic discussed in our pharmacy error injury blog from last week.

Keeping Accurate Health Records and Medication Lists Can Prevent Medical Errors

February 8, 2011 | Lebowitz & Mzhen

In a recent blog post, our Prince George’s County pharmacy error attorneys recently discussed the importance for individuals to communicate more effectively with their doctors and pharmacists, to promote the safe and effective use of drug therapy and reduce the risk of medication error.

Every year, according to research by the Institute of Medicine, 1.5 million people are injured by medication-related events. According to the APhA, an important step for medication error prevention is for individuals to carry accurate health records and current lists of prescription medication with them to show doctors and pharmacists that include the medications, the dosage, and the health conditions that the medication is treating.

The APhA claims that patient medication lists reduce the risk of medication duplication, incorrect dosages, pharmacy misfill, and other harmful drug side effects that could come from dangerous interactions. All patient allergies should also be clearly stated on the list, along with any other important information that could prevent medication error by providing emergency staff and pharmacists with important information that could be lifesaving.

The APhA also recommends that patients get to know their pharmacists, as next to doctors, pharmacists are the second most trusted medication experts and providers of healthcare needs.

In an earlier blog post our attorneys suggested other steps to take to reduce the risk of medication error injuries from pharmacy misfill or error:

Dangerous Safeway Pharmacy Mix-up Gives Pregnant Woman Wrong Medication

February 5, 2011 | Lebowitz & Mzhen

In recent news that our pharmacy misfill injury attorneys in Washington, D.C. have been following, a medication error occurred in a local pharmacy, after a pregnant woman in Colorado was mistakenly given the incorrect medication for another patient who had a similar sounding name.

According to KDVR-TV, Mareena Silva, who is six weeks pregnant, went to Safeway to pick up her antibiotics and was mistakenly given the prescription for Maria Silva, containing Methotrexate, a medication reportedly used to treat cancer.

By the time Silva realized the pharmacy misfill, she had already reportedly taken the first pill. Silva reportedly rushed back to Safeway, where the pharmacist recommended that she throw the pill up, as it had been 30 minutes since she took the medication. Her doctor then sent an ambulance to Safeway.

Methotrexate, the drug Silva took due to the prescription mix-up, can reportedly cause birth defects in an unborn baby. The drug is also reportedly used to cause abortions in pregnancies that are troubled. The manufacturer also warns that there have been reported deaths linked to the incorrect administration of this drug.

After picking up what she thought was the antibiotic, the pharmacist reportedly even stated that the prescribed drug was not good for a pregnant woman. What Silva didn’t realize at the time is that the pharmacist was talking about the Methotrexate.

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.