Hospital Pharmacy Errors

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).

Hospital Safety Grades Equip Patients With Knowledge About Local Facilities

August 14, 2022 | Lebowitz & Mzhen

Having to visit a medical center can be nerve-wracking because there may be a lot of unknowns, including what kind of quality of care you will be provided. Whether a hospital has had multiple pharmacy errors or other dangerous incidents at the hospital can be particularly important for patients and potential future patients to know.

According to a recent news article, a medical center in California faced the risk of losing its Medicare funding after state inspectors uncovered multiple dangerous incidents regarding proper drug distribution. In one incident, an 88-year-old woman was hospitalized for chest pain, and instead of receiving medication for her symptoms, she was mistakenly given two doses of a chemotherapy drug used to treat breast cancer, a condition that family members say she didn’t have. According to the patient’s daughter, a nurse dismissed the daughter’s concern that after being admitted to the medical center, at one point, she could not understand her mother over the phone and thus told the nurse that it sounded as if her mother had suffered from a stroke. Because of this growing concern, the patient’s daughter called the nurse the next day and requested the list of medications that had been prescribed for her mother. The woman died less than a month after being admitted to the medical center. In a confidential report, the state’s public health inspectors stated that the medication error “could potentially cause harm or serious adverse drug reactions to the hospital’s patients.”

In addition, in another incident at the same hospital, a patient with dementia and a history of falls attempted to walk unassisted in his room and tripped over a device. As a result, the patient suffered a fractured hip and was found on the floor by a nurse. According to the article, an alarm designed to prevent such falls by alerting staff when a patient leaves a bed had not been turned on. Doctors decided not to repair the patient’s help because of their belief that the surgery was unlikely to improve his quality of life, and that patient was placed on comfort care and died 7 days after the accident.

The Risk of Pharmacy Errors in Maryland Children’s Hospitals

December 6, 2019 | Lebowitz & Mzhen

For a parent, almost nothing is scarier than having your child be sick and in need of hospitalization. Unfortunately, parents across Maryland face this reality every day, relying on children’s hospitals and wards to protect their infants and children. Hospitals are supposed to keep their patients safe and take care of them to the best of their abilities, but, tragically, sometimes mistakes happen, jeopardizing the health and livelihood of young patients. One common type of mistake is pharmacy errors, when the incorrect medication or dosage is given to one or more patient. These errors are particularly concerning when the patients are infants or children, particularly vulnerable and potentially unable to communicate when something feels wrong.

When pharmacy errors happen, the results can be tragic, potentially leading to severe health concerns or even death. That risk is increased when the mistake is not immediately discovered, but rather continues to happen. For example, a children’s hospital in Cincinnati recently admitted to mistakenly giving several patients a wrongly mixed batch of blood pressure medication. According to a local news report covering the tragic incident, one of the victims affected is an 11-month-old baby, who received 54 doses of the incorrectly mixed drug. Each dose was ten times stronger than required, and although the infant survived, he suffered kidney damage as a result.

The hospital has not released much additional information. At this time, it is unknown how many other patients received the incorrect medication, for how long, or what adverse outcomes occurred. The hospital has also not made clear whether the incorrectly mixed medication was created in its own pharmacy or received from an outside supplier.

Distraction Is Among the Leading Causes of Maryland Pharmacy Errors

April 5, 2019 | Lebowitz & Mzhen

Pharmacists and nurses have a very important job that must be taken seriously at all times. However, medical professionals are human, and it is not uncommon for a nurse or pharmacist who is comfortable doing their job to begin to engage in multi-tasking. While the ability to multi-task is seen as a good thing in some contexts, when the safety of a patient is on the line, pharmacists should keep the focus of their attention only on the task at hand. As studies have repeatedly shown, a Maryland pharmacist who multi-tasks while filling a patient’s prescription increases the risk of a Maryland pharmacy error.

Back in 2017, a woman died after she was given a lethal dose of the paralyzing agent vecuronium instead of Versed, which the doctors intended to provide her with. According to a recent news report, prosecutors released additional documentation in the 2017 case showing that the nurse made at least ten errors in the moments leading up to the time when she gave the patient the lethal dose.

Evidently, a nurse administered the lethal dose of vecuronium to the patient, who stopped breathing a short time after the medication entered her bloodstream. At the time, the nurse admitted to being involved in an unrelated conversation with a colleague when she reached for the medicine. The nurse grabbed the wrong medication and apparently failed to notice the boldface type on the packaging stating WARNING: PARALYZING AGENT.

Many Maryland Pharmacy Errors May Be Linked to Electronic Prescribing

March 25, 2019 | Lebowitz & Mzhen

Over the past few decades, the demand placed on Maryland pharmacies has skyrocketed. The workload of the average pharmacist has correspondingly increased. In an attempt to keep the system working efficiently, pharmacies have begun to rely more and more on technology to help with filling prescriptions. This includes checking for prescribing errors and potential adverse reactions.

One of the most notable advancements is the widespread use of electronic prescribing and medication administration. The concept behind electronic prescribing and medication administration is that doctors and pharmacists can electronically input a patient’s prescription rather than rely on a “paper trail,” as used to be the case.

As a recent article points out, however, there may be unintended consequences of the widespread use of electronic prescribing and medication administration. The study reviewed the pharmacy staff’s daily behaviors before and after the implementation of an electronic prescribing and medication administration system. According to researchers, the new system may be linked to an increase in medication errors — the study based this conclusion on several data points.

Some Pharmacies May Lack Safeguards Protecting Patients Against a Physician’s Over-Prescribing

March 1, 2019 | Lebowitz & Mzhen

Pharmacists are medical professionals and – although it is not always evident to patients – a significant amount of work goes into filling each prescription. Aside from making sure that the correct drug, dose, and amount of medication is provided to a patient, pharmacists are also responsible for ensuring the quality of the medicine being provided to patients, and for making sure that prescribed medication is suitable for the patient.

The vast majority of the time, pharmacists deal with controlled substances that have not just the power to help a patient, but also the potential for danger. Some of these drugs may have serious side effects or exact dosing requirements, and many of the drugs handled by pharmacists can be habit-forming or addictive.

A recent article discussed the lack of safeguards in one hospital pharmacy that allowed a physician to overprescribe painkillers in fatal or near-fatal doses to 34 patients. Typically, the hospital required a pharmacist to approve a prescription electronically before a doctor or nurse can access the medication cabinet and obtain the drug to give to the patient. In the event of an emergency, access to the medicine cabinet was allowed through a physician override. Evidently, physicians were able to access all types of dangerous medications, including fentanyl and Versed, without having to justify the circumstances of the emergency.

ISMP Hopes Maryland Pharmacists Will Take Extra Precautions After Fatal Pharmacy Error

February 4, 2019 | Lebowitz & Mzhen

Recently, the Institute for Safe Medication Practices (ISMP) issued a report asking that Maryland pharmacists, as well as pharmacists across the country, take additional precautions in the wake of a fatal 2017 pharmacy error. The ISMP is a nonprofit organization dedicated to reducing the number of pharmacy errors across the United States. In furtherance of that goal, the ISMP operates a voluntary error-reporting system. The ISMP then uses this data to work with pharmaceutical companies to eliminate the root causes of common errors such as similarly named drugs, confusing packaging, and dangerous device design.

The Error

According to the ISMP report, a patient was admitted into the ICU with a headache and vision loss. An MRI was conducted, and it was determined that the patient had a hematoma of the brain. The patient was transferred, and a full-body scan was ordered. While the radiologist was explaining the procedure to the patient, the patient indicated she had claustrophobia. The radiologist requested the patient be given a dose of Versed to help with her claustrophobia.

Evidently, the patient’s primary nurse requested that a radiology nurse provide the patient with the medication. The radiology nurse declined, stating that the patient would need to be monitored after administration of the drug. The primary nurse indicated she would send another nurse to the radiology department to monitor the patient after she was given the medication.

Study Notes an Increase in Accidental Overdoses from Cancer Drug

July 2, 2018 | Lebowitz & Mzhen

Medical errors are all too common in hospitals throughout the country. In any Maryland medical error case, a plaintiff must show that the defendant was negligent in acting or failing to act in some way. There are four elements a plaintiff must prove in order to be successful in a medical negligence claim: a legal duty, a failure to perform that duty, causation, and damages.

Medical errors cases can be hard to prove in some cases because a plaintiff must show that the defendant’s actions or failure to act were the cause of the plaintiff’s injuries. This can be tricky, especially in medical error cases, because patients are often already sick and proving causation is not always clear-cut. Additionally, the issues involved in the case are often complex and involve scientific principles beyond the understanding of most people. For that reason, such cases often rely on the testimony of experts.

In some cases, an expert is needed simply to understand whether mistakes were made and who may be at fault. As one example, a recent study revealed the problem of accidental overdoses from a drug that has been used on cancer patients for many years.

Recent Hospital Pharmacy Error Was a Result of System-Wide Failures

April 9, 2018 | Lebowitz & Mzhen

Earlier this month, a man in a New Zealand hospital died due to opioid toxicity after he was administered what turned out to be a fatal dose of fentanyl. According to a local news report covering the story, the error was a result of system-wide failures across the spectrum of care providers.

The victim of the error was at the hospital for a routine knee surgery. The hospital had just implemented a new e-prescribing system the month before, whereby physicians could order medication at a patient’s bedside with one touch on a computer screen. The physician overseeing the victim’s care was attending to another patient when he remembered to put in an order for the victim’s medication. The physician input the medication order and then returned his attention to the other patient.

The physician, however, failed to switch the computer screen back to the patient who was with him. Thus, when the physician entered a medication order for fentanyl patches that was intended for the other patient, the order was sent to the victim’s file.

A Look at Hospital Pharmacy Errors

April 2, 2018 | Lebowitz & Mzhen

When most people think of picking up a prescription, a retail pharmacy comes to mind. However, each year, a significant portion of the overall prescriptions filled are filled by hospital pharmacies. While there are many similarities between hospital pharmacies and their retail counterparts, there are also major differences that can lead to an increased risk of hospital patients suffering from a Maryland pharmacy error.

According to a recent news report, one of the most likely scenarios in which a hospital pharmacy error occurs is during the transition from the Intensive Care Unit (ICU). Indeed, the report indicates that nearly 50% of all patients transferring out of the ICU experience some kind of pharmacy error.

The Results of the Study

The study, which was led by a clinical pharmacy research specialist, observed nearly 1,000 patients over a one-week period. Each of the patients was transferred from the ICU to another unit within the same hospital. The results were that 45.7% of all patients experienced an error with their medication, averaging about 1.88 errors per patient.