Hospital Pharmacy Errors

Recent Study Shows Hospital Pharmacy Errors Decrease with More Pharmacist Involvement

December 22, 2017 | Lebowitz & Mzhen

While many Maryland pharmacy errors occur at the thousands of retail pharmacies across the state, a large portion of the state’s overall pharmacy errors still occur in medical settings, such as hospitals, rehab facilities, and nursing homes. In fact, according to a recent study, some hospital patients’ medical records reveal as many as seven pharmacy errors. Of course, while not all of these are clinically significant, the trend is still disturbing.

Due to the number of pharmacy errors across the nation, as well as the potential that these errors can result in serious injuries or death, researchers have undertaken renewed efforts to discover new methods to decrease the rate of pharmacy errors. One place researchers are focusing their efforts is on patients who take a large number of prescription medications, based on the assumption that this population is at the greatest risk of experiencing an error.

According to a recent study, when pharmacists, rather than medical staff, take a patient’s history, the number of errors in subsequent prescriptions is drastically reduced. The way that many hospitals operate is that the job of entering a patient’s history belongs to anyone who works with the patient. While this may sound effective in that numerous medical professionals are reviewing a patient’s history, the result is that no single person feels accountable. However, when a single pharmacist is given the task of entering a patient’s history, that pharmacist is the sole person accountable, and as a result, the instances of errors drastically decrease.

Recent Study Indicates that Type 1 Diabetes Patients Are at Especially High Risk of Experiencing a Medication Error

November 1, 2017 | Lebowitz & Mzhen

In the pharmacy world, it is well-known that diabetic patients are among those with the highest risk of being victims of Maryland medication errors. This is due mostly to the fact that diabetic patients are often required to take several medications in a very specific dose, as well as the fact that a failure to get the medication (or too large a dose of the medication) will likely result in an adverse health event.

According to a recent study, those patients who suffer from Type 1 diabetes are more likely than patients with Type 2 diabetes to experience a medication error. The study followed 671 diabetic adults who were admitted to the hospital. Researchers tracked the patients from admission until discharge and double-checked each administration of medication. As it turned out, about 30% of patients experience at least one error.

The most common type of error accounted for roughly 60% of all errors and was an error of omission. When this type of error occurs, a patient is not given the medication that they were prescribed by their physician. Other common error types were wrongly added medications and improperly administered medications.

Study Shows E-Prescribing Has Decreased Pharmacy Error Rates

October 9, 2017 | Lebowitz & Mzhen

In the old days, a pharmacist’s job hardly resembled what it does today. With hundreds of patients coming in to fill tens of thousands of prescriptions each month, the average pharmacist is extremely busy. This leaves them with little time to spend with each patient, and it may even result in the pharmacist rushing through important safety measures just to keep up with the workload.

The situation in hospital pharmacies is similar; with patients constantly being admitted and discharged, it can be difficult for pharmacists to keep all of the patients and medications straight. This has led hospitals across the country to rely more on technology. And it seems to be working in reducing Maryland pharmacy error rates and rates in other states.

According to a recent news article, the use of electronic health records (EHRs) and computerized prescriber-order-entry (CPOE) systems has greatly reduced the number of medication errors in hospitals nationwide. As a result, these systems have been widely adopted, with approximately 99% of hospitals using EHRs and 97% of hospitals using CPOE systems to fill at least some portions of the prescriptions filled in the hospital.

The Risks of Pharmacy Compounding Errors in Hospitals May Be Under-Appreciated

September 15, 2017 | Lebowitz & Mzhen

Maryland pharmacy errors are shockingly common and have several causes. One cause that is rarely discussed is compounding errors involving intravenous (IV) medication. The use of IV medication is very common is hospitals. Normally, a nurse comes into a patient’s room with a small bag of fluid, connects the bag to the IV in the patient’s arm, and hangs the bag up near the patient’s bed. However, patients are only seeing a small part of what goes into preparing this medication.

In reality, there are many steps that must be taken before that bag of liquid is administered to a hospital patient. According to a recent industry news source, there are a number of ways that an error can occur when a pharmacist prepares IV medication. For example, the pharmacists in the hospital’s compounding center are rarely required to conform to the same protocol, resulting in each pharmacist having their own system for creating compound medications. In a busy pharmacy environment, this can result in a pharmacist overlooking a crucial step or making some other kind of hasty error.

Of course, when dealing with serious medications, the measurements must be precise. However, too often, pharmacists are essentially “eyeballing” the correct amount of medication by using small black measurement lines on the side of a syringe. In addition, much of the process relies on hand-written notes that can be misinterpreted, resulting in an increased chance of an error.

Grandfather Receives Wrong Medication, Inducing Coma

May 22, 2017 | Lebowitz & Mzhen

Medical errors can occur in a number of situations, including by filling a prescription with the wrong pills, operating on the wrong limb, or providing medication to the wrong person. These mistakes can be devastating for patients as well as their families.

In a medical malpractice claim based on a medical error, a plaintiff has to demonstrate that the medical professional acted negligently by either engaging in a negligent act or negligently failing to take a required action. That is, a plaintiff must show that the medical provider failed to meet the applicable standard of care by failing to act in a manner in which other medical professionals would act under the circumstances.

A 74-Year-Old Grandfather Fell into a Coma After Being Given the Wrong Medication

According to one news article, a 74-year-old man went into a coma after having been given the wrong medication at a hospital. Earlier this year, the man went to the hospital with flu-like symptoms. He was diagnosed with liver cancer and admitted to the hospital. After a couple of weeks at the hospital, he was given medication that was not prescribed to him.

Registered Nurses Too Often Fail as a Last Line of Defense Against Medication Errors

January 23, 2017 | Lebowitz & Mzhen

The results of a recently published study emphasize the crucial role that registered nurses (RNs) play in maintaining accuracy in dispensing medications to patients receiving inpatient services at a hospital. The recently performed study discusses the most common medications that are subject to error, as well as the rates of harm to patients that occur as a result of errors made by RNs. Costly errors appear to encourage doctors, hospitals, insurance companies, and the medical industry as a whole to issue guidelines in the hope of preventing errors. However, whatever harm these errors cause to the medical professionals who make them, the harm caused to innocent patients is significantly worse.

The Study Confirms the High Rates of Inpatient Errors Committed by RNs

An article in an industry news source (login required) discusses the recent study mentioned above. The study found that the majority of medication errors occurred in the medical-surgical units of the hospitals where they were conducted, followed by the intensive care units and intermediate care units.

Anticoagulant drugs were the most common type of medication to be associated with a medication error, and 10% of the total errors ultimately resulted in harm to a patient. Although 10% sounds like a low number, that still adds up to hundreds of thousands of patients each year who receive some type of medication error and thousands who suffer harm as a result.

Woman Dies After Inexplicably Receiving IV Containing Deadly Dose of Paralytic Medication as a Result of Pharmacy Error

December 22, 2016 | Lebowitz & Mzhen

Most deadly pharmacy errors can be traced to a mistake that may not be justifiable or excusable but is at least understandable. Errors such as dosage mistakes that result from a misplaced or removed decimal point, problems in which a patient receives the wrong medication because of a similarly named medication, or patients get mixed up by a pharmacy employee can usually be explained. Because of the serious, sometimes deadly consequences of prescription and pharmacy errors, the victims of these mistakes should be entitled to compensation if they or their loved one is injured, disabled, impaired, or killed as a result of a medical professional’s mistake.

65-Year-Old Woman Receives Paralytic Agent Instead of Anti-Seizure Medication

The unfortunate case of an Oregon woman who died after receiving an intravenous dose of a dangerous medication from an inpatient hospital in 2014 demonstrates that some pharmacy errors and prescription mistakes defy all logical explanation and simply cannot be reasonably explained. In this tragic instance, a woman who was physically healthy when she checked herself into a hospital for symptoms of anxiety was dead two days later after receiving a medication that she had not been prescribed and that should not have been administered to any patient in the dose that she received.

According to a local news report, law enforcement authorities have recently announced that they will not pursue criminal charges against the medical professional who prepared the IV containing the paralytic agent rocuronium instead of the anti-seizure medication, fosphenytoin, that the woman’s physician had ordered. Authorities announced that it would not be in the interest of justice to prosecute the wrongdoer, while implying that they did have sufficient evidence for a conviction in the tragic death.

Medical Mistakes Are the Third-Leading Cause of Death; Many Involve Pharmacy Errors

October 12, 2016 | Lebowitz & Mzhen

Many people are unaware, but medical mistakes are the third-leading cause of death in the United States, causing roughly 365,000 deaths per year. The category of medical mistakes is a broad category, including medical malpractice, diagnostic errors, surgical errors, and pharmacy errors.

Pharmacy errors occur when a pharmacist provides a patient with the wrong dose of a prescribed medication, the wrong directions on how to take a prescribed medication, or the wrong medication altogether. These errors may occur in the hospital setting or in a retail pharmacy, but errors occurring in the in-patient setting are even more frightening and surprising because the medication is actually delivered by a doctor or nurse. One would expect that this extra layer of interaction would result in most pharmacy errors being discovered before a medication is delivered to a patient, but that is not necessarily the case.

In a recent article discussing medical mistakes generally, as well as what can be done to prevent them, the writer mentions several precautions that can be taken to decrease the frequency of in-patient pharmacy errors. The first suggestion is to have pharmacists make rounds to see all patients in the hospital along with the doctors and nurses. The author explains that while doctors are in charge of a patient’s overall care plan, a pharmacist is a much-needed consultant when it comes to any potential interactions medications may have with one another. In fact, a recent study cited by the article notes that hospitals that have implemented this plan have seen a 94% reduction of serious pharmacy errors.

Recent Study Estimates In-patient Medication Errors Cost the U.S. Health Care System $16.4 Billion Annually

September 5, 2016 | Lebowitz & Mzhen

Medical errors account for a huge number of serious injuries and deaths across the United States each year. In fact, according to a recent report, medical errors are the third-most common cause of death in the United States. Included in the term “medical errors” are mistakes made by doctors, such as misdiagnoses, surgical errors, and medication errors.

No matter where in the health care system a serious error occurs, the medical professional responsible for the error may be held liable through a personal injury lawsuit. By virtue of caring for patients, doctors and pharmacists assume a responsibility to provide a certain level of care, as measured by the professional standard in that specific geographic area. When a physician’s or pharmacist’s performance falls short of this duty, they could be found liable for medical malpractice or general negligence, depending on the allegations.

According to a recent study conducted by the Institute of Medicine of the National Academies, approximately 1.5 million people are affected each year by medication errors. While many of these errors occur in the out-patient setting of retail pharmacies, a significant number of medication errors occur in the in-patient setting as well. In fact, according to a recent study conducted by the Network for Excellence in Health Innovation, preventable in-patient medication errors cost the U.S. health care system approximately $16.4 billion each year. This figure includes amounts for the treatment of preventable illnesses and diseases that were caused by medication errors, as well as the cost of hospital readmission. Importantly, this figure does not include the cost incurred from the many successful negligence and medical malpractice lawsuits that are settled or resolved each year.

Pharmacy Errors Involving Injectable Drugs Administered in Medical Facilities

August 15, 2016 | Lebowitz & Mzhen

When most people think of pharmacy errors, they think of a busy pharmacist behind the counter at a grocery store or retail pharmacy. However, pharmacy errors occur in all shapes and sizes and at all locations, including errors in medications that are administered in the hospital by medical professionals. Many of these errors include injectable medications that are given to the patient through an IV.

Of course, the ultimate burden of ensuring that a medication is safely administered to the patient lies with the pharmacist and, in cases of inpatient care, also with the nurse or doctor administering the medication to the patient. Whenever a patient is given the wrong medication or even the wrong dose of the correct medication, that patient may suffer a serious adverse reaction, potentially resulting in serious injuries or even death. In these circumstances, the patient or their family may be entitled to monetary compensation through a personal injury lawsuit. This is among the reasons that pharmaceutical companies take the possibility of errors involving their medication very seriously.

Pharmaceutical Company Develops System to Reduce Error Rates among Injectable Medications

It is estimated that the total number of errors involving injectable medications is roughly 1.2 million per year, making these errors not as uncommon as most people think. The cost of injectable medication errors reaches into the $5 billion range, and this figure cannot accurately take into account the pain and suffering of the patients and families involved. Because of the severity and frequency of these errors, one pharmaceutical company developed a specialized system to help combat injectable medication errors at hospitals across the country.