Hospital Pharmacy Errors

AHRQ Tips for Preventing Medical Mistakes with Children

March 30, 2010 | Lebowitz & Mzhen

In yesterday’s blog, our Baltimore, Maryland Medical Mistake Attorneys discussed leading causes of medical mistakes with children in this country, and important ways to prevent medical errors from happening.

According to the Massachusetts College of Pharmacy and Allied Health Sciences, 88% of medication errors involve the wrong dosage or incorrect drug. The Agency for Healthcare Research and Quality (AHRQ), the lead Federal agency that supports research to improve the quality of healthcare, addresses the importance of patient safety and the cause of many medical errors in a recently published press release.

In the press release, the AHRQ addresses the large problem of medical mistakes with children in this country, and gives parents and guardians tips on how to prevent these medical errors from happening with children, to avoid personal injury.

According to the AHRQ:

• Being involved in your child’s healthcare is the most important way to prevent medical errors or pharmacy misfills. The AHRQ stresses that it is extremely important for parents or guardians to take part in every decision that is made regarding the healthcare for a child.

• Make sure that your child’s doctors know every detail regarding the history and statistics (height and weight) of your child, every prescription, all over the counter medications, and any vitamins or dietary or herbal supplements, as well as any known allergies to any medication.

• At least once a year, bring a bag of everything your child is taking and go through each one with the doctor to ensure that there is no problem or conflict with any medication.

• Make sure you can read every prescription that the doctor writes. Double check the name and dosage, or if there is any question, have the doctor re-write the prescription in capital letters, printing the name of the drug and the dosage. If you can’t read the doctor’s handwriting, chances are the pharmacist will not be able to either.

Keeping Children Safe—Eliminating Mistakes from the Children’s Healthcare Industry

March 29, 2010 | Lebowitz & Mzhen

In our last blog, our Maryland Attorneys from Lebowitz and Mzhen Personal Injury Lawyers, discussed a recent pharmacy misfill, where an 8-year old boy received the wrong dosage of a medication that could have caused the child serious personal injury or even wrongful death.

According to the Agency for Healthcare Research and Quality (AHRQ), medical errors are one of the leading causes of injury and death in this country. The AHRQ reports that in a recent study, 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.

The National Coordinating Council for Medication Error Reporting and Prevention, (NCCMERP), estimates that nearly 98,000 people experience death from medical errors that occur in hospitals every year. Medication errors can happen at any point in the healthcare process and system and can result in injury—from miscommunication with doctors, to prescribing the drug, dispensing drugs at the pharmacy, or in the administering or the process of monitoring the drugs.

The AHRQ recommends that single most important way to prevent medical errors from happening to your child, is to be an active participant with the healthcare team that is caring for your child. Research shows that parents who are involved in all aspects and decisions of a child’s care experience better and safer results.

Hospitals Fined by CDPH for Alleged Medication Mistakes

February 1, 2010 | Lebowitz & Mzhen

In recent article that our Maryland-based Medical Mistake Attorneys have been following, The California Department of Public Health (CDPH) has fined 13 hospitals in California $650,000 for 16 medical mistakes that have caused serious patient injury, harm, or even wrongful death in 2008 and 2009.

In one hospital pharmacy error in Oakland, California, a 90-year old emergency room patient at Kaiser Foundation Hospital, received a variety of blood pressure and stomach ulcer medications that were meant for another patient. The emergency room staff did not double check the medication orders sent from the pharmacy, and the patient went into severe respiratory distress after receiving the potassium chloride by mistake.

A rapid response team was sent in and the patient was reportedly breathing four to six breaths per minute with a fluctuating blood pressure. The man was intubated and put on a ventilator for breathing. Further testing proved that the patient lost brain function from the medication error. A physician interviewed by the California Health investigators claimed that he could not rule out the possibility that the medication mistake caused a severe change in the patient’s health.

In another case, at California Hospital Medical Center in Los Angeles, a patient was incorrectly given the drug Methotrexate, or chemotherapy, as a treatment for ectopic pregnancy—even though the patient was not in fact pregnant. Over the following week, the patient reportedly developed immune suppression, renal function decline, severe leukopenia and neutropenia, and oral, skin and esophageal ulcerations due to the medication error. The investigators reported that using chemotherapeutic medication on a patient who was not pregnant subjected the patient to serious health complications, physical harm, and injury.

Lawsuit Accuses Hospital of Medication Mistake and Wrongful Death

January 27, 2010 | Lebowitz & Mzhen

In a recent lawsuit that our Maryland Pharmacy Mistake Lawyers have been following, a hospital is being sued for dispensing an overdose of pain medicine to a 68-year old woman, which allegedly led to her wrongful death.

Mable Mosley was taken to the Brandon Regional Hospital last year complaining of neck and shoulder pain. She checked into the hospital on a Saturday, and within a few days stopped breathing. Mosley was put on life support, and died days later.

Mosley’s husband is suing the hospital, the hospital owners, and seven individual pharmacists in the case, claming medication negligence and wrongful death—that his wife was given enough pain medicine to end her life.

The drug in question that Mosley received is called Duragesic, a patch containing large concentrations of opioid fentanyl, a potent narcotic approved in 1990 by the FDA for use in patients that have become opioid-tolerant from using another strong narcotic pain medication for a week or longer.

Opioids are chemicals that are commonly prescribed because of their pain relieving properties. Opioids work by attaching to opioid receptors, or proteins, found in the brain, spinal cord and gastrointestinal tract. When the drugs attach to the opioid receptors, they can block out the body’s perception of pain.

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.

Understanding the Prescription Drug’s Path through a Pharmacy can Reduce Error

December 28, 2009 | Lebowitz & Mzhen

In a recent study that our Maryland Pharmacy Error Attorneys have been following, USA Today investigated every step of a prescription’s path in a pharmacy—to uncover the potential for medication mistakes with each step of the filling process, that can lead to patient injury or wrongful death.

In the research, USA Today interviewed pharmacy experts and toured two pharmacies, a CVS and Walgreens, to study the six steps of the prescription filling process, and the potential errors that can happen along the way, as well as real cases that have caused actual injuries or death.

Step 1: Prescription received

When the customer drops off the prescription to the technician, or the doctor’s office calls in the prescription, errors can occur if a technician misunderstands a doctor’s handwriting, prescription codes and abbreviations or misunderstands the oral instructions over the phone. In one case, a doctor’s prescription for methadone read “sig 4 tablet BID for chronic pain,” which means “Please label (sig) this drug to say: take 4 tablets twice per day (BID) for chronic pain. The technician typed, “Take 4 tables by mouth as needed for chronic pain.” The patient allegedly died of an overdose of methadone.

Step 2: Prescription entry
A technician then scans the original prescription into the computer and manually enters the patient’s personal data, like name, address, date of birth and phone number, as well as drug information, strength, dosage instructions and quantity. If a technician incorrectly types the prescribed drug dosage, formulation or the patient’s medical condition, history or allergies into the computer, then serious errors can occur, including personal injury. Also if the wrong drug code is chosen in the computer system, it can be mistaken for a similarly named drug. In one instance, a pharmacy was asked to fill a prescription for compazine, an anti-nausea drug, (COM) and accidentally gave the patient a generic substitute for coumadin, a blood thinner (COU).

QJM: How to Prevent Medication Errors and Injury with Balanced Prescribing

November 30, 2009 | Lebowitz & Mzhen

As Maryland Medication Mistake Attorneys we have recently read an article published in the QJM, the long-established leading general medical journal, on the topic of medication errors—giving an overview of what medication mistakes are, how they happen, and how to prevent them from happening in the future.

According to the article, published in August 2009, a medication error is a failure in the process of treatment that can lead to the harming or personal injury of a patient. Medication errors can often occur in:

• Prescribing faults: ineffective prescribing, irrational or inappropriate prescribing, under-prescribing and over-prescribing when deciding which treatment and dosage plan to take.

• Prescription writing: illegibility
• Formulation manufacturing: incorrect strength, misleading packaging
• Drug formulation dispensing: incorrect drug, formulation and label
• Administering the medicine: incorrect dosage, wrong directions for frequency, invalid duration of treatment
• Monitoring drug therapy treatment and drug treatment alteration when required

Medication errors can be classified, according to the article, by the use of psychological error classifications—knowledge-errors, rule-errors, action-errors, and memory-based errors. It is important to detect the medication mistakes, that can range from trivial to serious, and to create a working environment that is free of blame, and encourages the reporting of errors.

The article also recommends, “balanced prescribing” to avoid medication errors. In balanced prescribing, the mechanism of action of the drug should complement the pathophysiology of the disease—optimizing the balance of benefit to harm.

Alert for Public Safety—FDA Reports Medication Error with Tamiflu

November 18, 2009 | Lebowitz & Mzhen

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:

Dangerous Drug Abbreviations that Lead to Medical Injury

November 13, 2009 | Lebowitz & Mzhen

In the ongoing topic of medical error and injuries that our Maryland Medication Mistake Lawyers covered earlier this week in a previous blog, the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) recommends that in order to help prevent medical error injury and death every year, it is important that the prescribers of medication avoid the use of dangerous abbreviations in prescriptions, including those for drug names and Latin directions for use.

The current NCCMERP list of dangerous abbreviations commonly made by prescibers include:

• Mistaking “µg” for “mg” or milligrams, resulting in an overdose

• “U” is mistaken for zero or a 4, which also results in an overdose. “U” is intended to mean “Units” but with poor handwriting, it can also be mistaken for “cc” or cubic centimeters.

• “Q.D.” means “every day” in Latin. The period after the “Q” is sometimes mistaken for an “I”—and the drug is given “QID” (four times daily), which results in an overdose.

• “T I W” means three times a week. This is often misinterpreted as “three times a day”
• “IU” means International Unit, and is often mistaken for “IV” or intravenous

• “AU, AS, AD” are the Latin abbreviations both ears, left ear and right ear. These are often misinterpreted as the Latin abbreviation “OU” (both eyes), “OS” (left eye), and “OD” (right eye)

The Council also recommends that in order to enhance the accuracy of prescription writing and communications, doctors, nursing and pharmacy staff should:

• Make sure all prescriptions are legible and include notes on medication purpose—like cough, or allergies—maintaining that the proper medication is dispensed.

• All prescription orders should be written in the metric system, except for orders that use standard units like vitamins or insulin. Units should also be written out, rather than abbreviated with “U”

• Medication orders should include the exact drug name, metric weight or concentration, dosage form, with strength and concentration expressed in metric amounts.

• The NCCMERP reports that numerous errors in drug strength and dosage have occurred with the use of decimals—due to the trailing zero (1.0 mg) or the lack of a leading zero (0.1 mg). A leading zero should always be used before a decimal, and trailing zeros should never be used.

Death from Medication Error Leads to Prevention Awareness

November 10, 2009 | Lebowitz & Mzhen

As Maryland Medication Error Injury Attorneys, we have recently read data from the U.S. Food and Drug Administration (FDA) stating that in the United States, 1.3 million people are injured by medication errors every year, with at least one death reported every day.

According to the National Coordinating Council for Medication Error Reporting and Prevention, (NCCMERP), injury from medication error is an urgent, a widespread public problem, that needs to receive far more public attention. The NCCMERP estimates that 98,000 people die annually from medical errors that occur in hospitals—an amount that is greater than deaths from motor vehicle accidents, breast cancer, AIDS, even workplace injuries. Medication error can happen at any point, and result in injury—from communication, distribution, prescribing, dispensing, administering or monitoring.

A medication error is defined by the the NCCMERP as any event that is preventable, and may cause medication misusage or patient harm while the medication is being controlled by the health care professional, consumer or patient. Medication errors can happen in professional practices and during procedures, as well as in the systems of prescribing, ordering, the labeling of a product, packaging, dispensing, education, monitoring, usage, and naming conventions.

The FDA states that common causes of medication error stem from poor communication between doctor, pharmacist, and patient, with unclear product names or suffixes, medical abbreviations or handwriting, poor techniques or procedures, or a lack of understanding of directions for patient usage. Job stress or lack of training or knowledge can also lead or contribute to pharmacy error injury or misfills.