Articles Posted in High Alert Drugs

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.

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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.

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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.

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In yesterday’s blog, our medication error attorneys discussed a recent accidental overdose of epinephrine that led to a man’s death in a hospital. According to the FDA, Epinephrine is a high alert medication that could cause significant patient harm or injury when used in error. Medication error can occur when there is confusion in regard to epinephrine product ratio strengths. The Institute for Safe Medication Practices, ISMP, has received a number of fatality reports due to miscalculations of strengths of epinephrine injections.

In similar epinephrine news, the Institute for Safe Medication Practices (ISMP), and the American Society of Health-System Pharmacists (ASHP), announced a National Alert Network (NAN) message this month, to warn healthcare providers about dangerous medication mistakes that could be caused by a shortage of pre-filled epinephrine syringes.

The NAN warning states that emergency syringes of epinephrine in 1mg/10mL (0.1 mg/ml) are currently on backorder from the Hospira Inc., the only manufacturer of the product after the pharmaceutical company Amphastar stopped making its emergency syringes of the drug in 2009.

According to ASHP’s director of medication use, quality and improvement, Bona Benjamin, Epinephrine is a life saving drug used in ambulances, hospitals and any other emergency settings when a patient’s heart has stopped.

Benjamin claimed that the shortage of epinephrine does not effect quantities of the EpiPen, the epinephrine injection products that are self administered in .3 mg and .15 mg doses, to remedy severe emergency reactions to food, medication, insect bites, and other reactions of an allergic nature.

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Our Maryland Medication Error Attorneys have been reading about the tragic incident that happen in Maine recently, after a local man went to the emergency room with symptoms of anaphylaxis, and was given an overdose of the drug epinephrine—causing his wrongful death.

After suffering an allergic reaction from eating seafood that included facial swelling and thickening of the tongue, Timothy Harvey, 51, went to the Mayo Regional Hospital emergency room for treatment. Harvey was reportedly given 0.3 milligrams of epinephrine, and reportedly showed good signs of improvement.

While Harvey was being observed by the hospital staff, he had another allergic attack, with some of the earlier symptoms. The staff reportedly gave him another dose of epinephrine, but accidentally administered an incorrect dosage of the drug, causing a medication error that was ten times the normal dose, 3 milligrams instead of 0.3 milligrams.

According to the FDA, Epinephrine is a high alert medication that could cause significant harm or patient injury when used in error. When Harvey started to experience chest pain and shortness of breath, the medical team discovered the mistake, and immediately contacted the poison control center to attempt to reverse the effects of the drug, but with no success. The Epinephrine overdose ultimately killed Harvey, despite the hospital staff’s many attempts to save his life.

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Our Maryland Pharmacy Error Injury Lawyers have been following the recent case filed last week on behalf of John Sheridan, a man who died after being prescribed the wrong dosage of a cancer medication.

According to the suit, Sheridan was prescribed Temodar, a powerful drug for brain tumors that was part of his treatment of cancer in September 2007. The prescription was allegedly written incorrectly, and Sheridan was wrongly prescribed 10 times the correct dosage—he reportedly took the medicine daily when it was only to be used every other week. Rite Aid Pharmacy allegedly dispensed the drug to Sheridan, without checking with Sheridan’s oncologist for a second opinion to clarify the prescription mistake.

The lawsuit accuses a Rite Aid pharmacy for contributing in the wrongful death of Sheridan, who reportedly had consumed toxic doses of the cancer medication. According to the Associated Press, the doctor who wrote the incorrect prescription has settled with Sheridan’s estate.

According to a 2006 report from the Institute of Medicine, at least 1.5 million Americans are injured by medication mistakes every year, and nearly 7,000 people die every year from medication errors annually.

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The FDA has recently published a patient safety alert, reporting medication dosage errors associated with Tamiflu, (for oral suspension), the top doctor prescribed anti-viral flu medication, administered to both adults and children. Our Maryland Pharmacy Misfill Injury Attorneys have been following this prescriber and pharmacy alert report, and how it could effect patient safety in this current H1N1 influenza pandemic.

According to the agency alert, the FDA has received reports that the Tamiflu (oral suspension) dosing instructions for the patient do not match the dosing dispenser. U.S. health providers often write liquid medicine prescriptions in teaspoons or milliliters (mL), while the dosage of Tamiflu is in milligrams (mg). Prescribers and pharmacists have been warned that Tamiflu’s dosing dispenser included in the package has markings only in mg—30, 45, and 60.

The alert recommends that:

The medication error attorneys at Lebowitz & Mzhen Personal Injury Lawyers recently learned that the Food and Drug Administration has warned consumers who use medicated skin patches to remove those patches before going through a MRI scan. According to the FDA, some patches contain metal which may heat up during an MRI and burn the patient’s skin. The FDA warns that the metal in many of these patches may not be visible to the patient and not all transdermal patches that contain metal have patient warnings printed on the box. The FDA is currently reviewing the labeling requirements to ensure that patients are adequately warned of this new danger.

Until this review is complete, the FDA suggests that patients who use medicated patches do the following:

• Before undergoing an MRI scan, tell your doctor that you are using a patch and why you are using it;

According to the National Coordinating Counsel for Medication Error Reporting and Prevention (NCC MERP), medication errors kill more Americans annually, than work place accidents. Maryland lawyers who pursue prescription error cases recognize the financial and human impact that errantly filled prescriptions have on the citizens of this state. Pharmacy negligence is one of the most pressing health concerns across the nation due to the sheer number of people affected by errantly filled prescriptions.

Some common types of medication errors include:

• Incomplete patient information (i.e. not knowing about patient’s allergies, other medicines they are taking, previous diagnoses, and lab results);

It is clear that patients are put in danger by simple things such as penmanship and the use of inconsistent abbreviations. This must change. Maryland pharmacy negligence attorneys work with clients to hold negligent pharmacist responsible for the injuries that they cause across the state.

Your doctor hands you a prescription that you quickly take to your local pharmacy to fill. You look down at the unintelligible handwriting and find that it looks like a foreign language full of jumbled, incomprehensible abbreviations. Doctors, physician’s assistants, and other medical professionals often use abbreviations on prescriptions in order to save time. Too often, unfortunately, pharmacists misinterpret abbreviations used on prescriptions and, as a result, Maryland patients are put at risk of injury or death caused by improperly filled prescriptions. From January 2000 to August 2004, 498 health care facilities reported 19,000 medication errors caused by a pharmacist’s misinterpretation of another doctor’s short hand.

A pharmacist in Virginia misread a doctor’s abbreviation and dispensed two times the proper amount of heparin to a patient. As a result, the victim suffered a massive hemorrhage. The pharmacy ultimately settled the plaintiff’s case for $200,000.

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