Health Care Technology

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.

Medication Error Reduced By “Scanning” Patients for Electronic Records

October 28, 2010 | Lebowitz & Mzhen

In a related blog, our Baltimore, Maryland medical error attorneys discussed a recent study showing that implementing electronic health records significantly reduces medical and medication error, by integrating various systems across the country with hospitals and medical groups, to create a common platform for sharing patients’ medical records.

Health-care providers at the Tucson Medical Center (TMC) are reportedly achieving great success with a new electronic system using computerized scanning to verify their work. The electronic system is part of a new protocol at the medical center that was launched on June 1, 2010, after a $30 million upgrade to its electronic medical records system. Under the new system, each patient receives a bar code that is printed on a hospital bracelet. In an effort to reduce medication error and patient injury, before health-care providers can administer any medication, or perform any lab tests, the patient’s bracelet must be scanned, similar to a grocery checkout scanner. The medication must then also be scanned, to make sure that both the dosage and medication match the prescription for the patient.

In the preliminary three months of the new protocol, the system reportedly sent out around 1,500 medication error alerts that the health-care providers immediately corrected. Common medication errors like confusing continuous release and sustained release were also remedied, as the computer caught the medication errors after the patient’s bracelet was scanned.

According to Frank Marini, the CEO and vice president at TMC, the medical center implemented the electronic medical records in 2002, but still had paper charts for patients up until this year. Under the new federal health-reform law electronic medical records are a requirement.

Study Reviews Risk Levels Associated with Pharmacy Drug Dispensing

August 26, 2010 | Lebowitz & Mzhen

As Washington D.C. pharmacy error injury lawyers, we have been following recent study results released by the company Centice, that discuss the risk levels associated with drug dispensing processes, and the occurrence of pharmacy errors or misfills.

Centice is a company focused on the chemical verification of dispensed prescription drugs, and has recently published findings from that investigate levels of risk in the dispensing process for prescription drugs from Pharmacy Quality Assurance and Rx Verification Study.

According to the study’s research, after a single pharmacy error in the dispensing process, pharmacists can spend up to fifty hours correcting the dispensing error, or Quality Related Event (QRE).

Centice claimed that when looking at the total prescriptions filled, pharmacy error rates are very small, but when factored into dispensing many prescriptions over a period of time, given average pharmacy filling volumes, any prescription error that leaves the pharmacy can impact customer retention and the financial stability of the pharmacy, and could also lead to potential patient injury or even wrongful death.

E-prescribing Usage Increases with Doctors, but Not Without Problems

August 2, 2010 | Lebowitz & Mzhen

As our Washington D.C. Pharmacy Error Injury Attorneys reported in a recent blog, physicians who are not prescribing medications electronically, or e-prescribing, by 2012 will be financially penalized by the federal government.

Although the use of electronic prescribing has increased in years, and evidence shows that e-prescribing can reduce pharmacy misfills that can lead to patient injury or even wrongful death, many local doctors reportedly clam that overall acceptance of this important technology is lagging.

According to a study published last week by the Washington-based think tank, the Center for Studying Health System Change, less than one-third of this country’s physicians in office settings, are e-prescribing. The study also revealed that even fewer physicians that were e-prescribing were using the beneficial aspects of the system, like searching for serious drug interactions and using the system to cross reference patient insurance for prescription drug verifications to ensure health plan payment coverage. The study also found that even fewer doctors who used the electronic system would actually prescribe medications electronically, opting to use the fax machine instead for prescription submittal.

The Institute of Medicine (IOM) claims 1.5 million people in this country are injured by preventable medication errors, with nearly 7,000 deaths every year.

USP Advisory Panel Pushes for Prescription Label Standardization

July 29, 2010 | Lebowitz & Mzhen

According to the Institute of Medicine (IOM), the misuse of medication results in over one million adverse drug events every year. In a recent blog, our attorneys discussed the current efforts made by the U.S. Pharmacopeial Convention (USP) to establish a universal standard for prescription drug labels and instructions, by issuing a series of recommendations in order to add more consistency to prescription labeling—to reduce medication errors that can result in personal injury or wrongful death.

The USP is a Maryland-based nonprofit organization that issues standards that are legally enforceable for the quality, strength, and purity of medicines in this country. In 2007, the USP developed the Health Literacy and Prescription Container Labeling Advisory Panel to examine the different ways prescription drug labeling could be improved.

The IOM claims that health literacy affects ninety million adults, who are unable to benefit properly from the health care due to a lack of understanding of drug instructions and information about medication interactions. After the IOM called for new drug label standards, the USP panel recently released recommendations that are based on patient well being, and health literacy—as bad health literacy can cause medication errors, and increase the potential for heath risks and personal injury.

According to Joanne G. Schwartzberg, co-chair of the panel, standardizing the medication labels can markedly improve the health and safety of patients, by providing reliable, simple and straightforward information. The USP panel recommendations cover the appearance, content, format and languages on prescription labels, in an effort to optimize patient understanding, and eliminate medication error and misuse.

Forum Guidance Leads FDA to Help Reduce Medication Errors

July 26, 2010 | Lebowitz & Mzhen

According to recent news that our Washington D.C. pharmacy error injury attorneys have been following, the U.S. Food and Drug Administration (FDA) has committed to reduce medication mistakes by publishing a draft guidance by the end of this fiscal year. The FDA states that one third of medication errors, including 30% of errors ending in deaths that are reported to the Institute of Safe Medication Practices (ISMP), may occur as a result of drug labeling and packaging.

The FDA reportedly claimed that medication errors often happen as a result of names that look alike or sound alike, encoded numerals, failure to recognize active ingredients, dangerous medical abbreviations, and name length.

In a FDA workshop last month, Carol Holquist, RPh and director of FDA’s Division of Medication Error Prevention and Analysis reportedly claimed that guidance on these medication mistake issues is an important first step to developing a consensus to form new FDA regulations, which can take around 10-15 years.

The American Society of Health-System Pharmacists (ASHP)’s director of Medication Use Quality Improvement, Bona Benjamin, also reportedly told the workshop group that the ASHP’s 2007 recommendations for the FDA are still current—that human factoring should be applied scientifically to drug packaging and labeling, and barcode verification should be encouraged, as nearly 20% of hospitals are using barcode medication verification.

ISMP Reports of New Medication Errors Leading to Drug Omissions

March 1, 2010 | Lebowitz & Mzhen

A recent article from the Institute for Safe Medication Practices (ISMP) that our Maryland-based medication error attorneys have been reading reported that the order management scanning system (OMSS) technology that was created to improve the efficiency and safety of the drug ordering process for doctors and pharmacies, is now experiencing error-prone problems that are leading to medication errors, drug omissions and missed drug therapy in patients.

OMSS is a technology that was created to capture a digital image of a handwritten or printed prescription order and send it to the pharmacy—eliminating faxing, the use of a courier, or the use of pneumatic tubes to transport the information to the pharmacist. The idea behind OMSS was to accelerate the time the prescription hit the pharmacy, speed up the prescription filling process, with electronic filling, easy retrieval of scanned orders, and reduce the risk of transcription errors because the order can be magnified. Unfortunately, according to the article, these OMSS benefits are null and void if the pharmacy never receives the prescription orders.

The problem that is reportedly occurring is that multiple pages of orders are being pulled through the scanner at the same time, and the scanner is only reading a single page at a time—a problem that has also plagued pharmacies with faxing or copying orders in the past. When this problem occurs, staff may not be aware that only one page was scanned, and the pharmacist may not be aware that they should have received multiple pages of orders. As a result, drug omissions can take place, leading to medication mistakes or missed drug therapy.

In one documented case, a physician wrote three pages of admission orders for a patient suffering from lung cancer, as well as difficile colitis and fever. When the orders were scanned with OMSS, the pharmacy only received two pages of the orders, because one page was not pulled through. Neither the nurse who administered the medication the physician, nor the pharmacist noticed the prescription error and omission. The drugs prescribed on the missing page were seizure medications. By the forth day of receiving only a fraction of the medication, the patient was exhibiting behavior that lead the emergency response team to determine that the patient was having a seizure. The patient was transferred to critical care unit, where the doctor figured out the pharmacy mistake, and although the patient required intubation, he ultimately experienced a full recovery.

Incentives to Using Electronic Health Records in Physician Practices

February 24, 2010 | Lebowitz & Mzhen

Recently, our Maryland Medical Mistake Lawyers wrote about the use of electronic health records in hospitals and doctors’ offices, and how computerized health records have the potential to improve the health care of patients, and reduce the risk of medical errors and personal injury.

In the blog, our pharmacy error attorneys wrote about how President Barack Obama’s economic stimulus included over $19 billion for health information technology, and has given many hospitals great incentive to add their own funds and invest in adopting electronic records to improve the quality, safety, and efficiency of health and medical care.

One example of this comes from an article in the New England Journal of Medicine from last month, where the Long Island North Shore Hospital System in New York stated publicly that it will pay an up to $40,000 incentive offer to each doctor who agrees go electronic with health records—paying 50 percent of the total cost to doctors who install the Electronic Health Record that will communicate directly with the hospital, and will pay 85 percent of the total cost if the doctor shares quality care data.

The payment would reportedly add to the $44,000 physician incentive offer, where the American Recovery and Reinvestment Act of 2009 gave authority to Medicare to compensate health care professionals eligible for the payment, who used electronic health records in a meaningful way. According to the article, ‘meaningful use” is not yet clear in definition, but the overall aim is to transform the health care delivery system by using electronic records, to improve communication, efficiency, and quality care and reduce the risk of personal injury through medical mistakes or pharmacy error.

Reducing Medical Error by Implementing Electronic Health Records

February 23, 2010 | Lebowitz & Mzhen

In a recent post, our Maryland Medical Error Attorneys discussed how computerized health records have been used by the Veterans Health Administration for the past decade, with great reported success. These electronic records have reportedly improved the health care and well being of nearly eight million veterans, by storing information electronically about the prescriptions, studies, laboratory tests, consultations, doctor’s notes and any reports about the patient in any Veterans Affairs hospital—reducing the potential for medical errors or personal injury.

Yesterday The New York Times published an article discussing the reported benefits of electronic records, and how President Obama’s economic stimulus that included $19.2 billion for health information technology, has given many hospitals incentive to invest in creating and using electronic records to improve the efficiency, quality, and safety of medical care. The goal according to the article is to integrate the various systems across the country with various hospitals and medical groups so medical records can be shared on a common platform within the different systems.

According to the article, the benefits of electronic health records are:

• If the doctor has immediate access to a patient’s record, it could reduce medical errors and personal injury within the hospital setting due to drug complications, pharmacy errors, drug allergies, or potential drug interactions, as well as drug recalls.

• Electronic records can eliminate duplicate tests, from M.R.I.’s to blood tests. If a patient is seeing multiple doctors, a new doctor can easily access their test results electronically within the same system, which can prove to be valuable in a life-threatening situation. If a test needs to be repeated, the doctor will have access to the results of the last test to compare.

Steps for Preventing Prescription Errors in Pharmacies

December 29, 2009 | Lebowitz & Mzhen

In a related blog from yesterday, our Maryland Pharmacy Misfill Lawyers discussed a recent article from USA Today, where the step-by-step process of how a prescription is filled was followed in two pharmacies—to uncover how pharmacy mistakes are taking place, and how to prevent them in the future.

The article revealed how the possible errors are made and also discussed what steps pharmacies are making to try and prevent these errors, and reduce the number of pharmacy mistakes and patient injuries that could happen in the future.

Pharmacies are trying to prevent errors by:

• Encouraging improved communications between doctors and pharmacies.

• Encouraging doctors to write the prescriptions in full length, instead of using medical codes or abbreviations.

• Trying to transition from prescriptions that are handwritten to electronic prescribing—where a doctor sends the prescription directly from the doctors’ offices to the pharmacy computers.

• Computers are being used to aid the prescribing process, with more alerts for drug interactions, allergies, or patient’s illnesses.

• Other computer safety features include popup boxes when a technician enters or confuses a drug name with similarly named drug. After the popup appears, the technician has to initial the box to show he checked the drug.