Hospital Pharmacy Errors

Study of “Collaborative Pharmaceutical Care” Finds 3/4 Reduction in Hospital Medication Errors

March 19, 2014 | Lebowitz & Mzhen

A new study, conducted in Irish hospitals and published in a British journal, reviewed the effectiveness of a “collaborative” model of managing hospital patients’ medications. The model, known as the Collaborative Pharmaceutical Care in Tallaght Hospital (PACT), involves close involvement of clinical pharmacists in all stages of patient care during their stay in the hospital. The study, which was uncontrolled, found that PACT resulted in a reduction in the rate of medication errors by more than three-fourths.

The study was published in the online edition of the British Medical Journal Quality & Safety on February 6, 2014. The researchers compared the benefits of PACT to “standard ward-based clinical pharmacy,” with a focus on adult hospital patients receiving acute care, who were prescribed at least three medications in the hospital, and who left the hospital alive. The study included 112 patients receiving care based on PACT, and 121 patients receiving standard care. They measured the rates of medication errors and of potentially severe errors per patient.

According to the description provided in the study, the primary goal of PACT is to reduce the rate of medication errors that commonly occur when a patient is transferred between doctors or departments within a hospital, or transferred from one facility or organization to another, by improving the process of “medication reconciliation” (MedRec). This involves comparing a patient’s current medication orders to the medications a patient has been taking in order to prevent omission of a necessary drug, inclusion of an unnecessary or dangerous drug, or incorrect dosages.

Over-Prescribing of Antibiotics May Be Putting Hospital Patients at Risk

March 12, 2014 | Lebowitz & Mzhen

Lebowitz & Mzhen

March 12, 2014

Updated: March 12, 2014 12:59 pm

Proposed Laws Increasing Ratio of Pharmacy Technicians to Pharmacists Could Adversely Impact Patient Safety

March 5, 2014 | Lebowitz & Mzhen

Pharmacies often rely on a team of medical professionals to meet the demands of customers. These teams consist of pharmacists, who must meet educational and licensing requirements in all U.S. states and the District of Columbia; and pharmacy technicians, who are not always subject to such strict credentialing requirements. Some states set a maximum ratio of pharmacists to pharmacy technicians, while others simply require that the pharmacist have adequate support from staff and technology to perform their professional duties. Pending legislation that would increase the number of technicians that can work under a pharmacist has raised concerns about patient safety.

To obtain a pharmacy license, an individual must obtain a degree from an accredited pharmacy school, pass several examinations, and maintain continuing education requirements. Many states do not require as many credentials to work as a pharmacy technician. Maryland requires a person to have a high school diploma or equivalent, complete a 160-hour training program or obtain certification from a national pharmacy organization, and complete annual continuing education. Supervision of pharmacy technicians by licensed pharmacists is critically important to patient safety.

According to a report by Tampa’s WFTS on pending legislation in Florida, errors occur in an estimated 0.09 percent of all prescriptions filled in the United States. While this seems like a small number, the Kaiser Family Foundation estimates, based on data from 2011, that doctors write more than 59 million prescriptions per year in Maryland alone. That means that more than 53,100 pharmacy errors may occur per year in this state. Most of these errors do not cause any harm, but injuries from pharmacy misfills can be severe.

Hospital Uses “Storytelling” Approach to Prevent Medication Errors

February 13, 2014 | Lebowitz & Mzhen

A hospital in Houston, Texas has adopted a “narrative-based approach” of communicating the details of medication errors to hospital staff (login required). A medication safety consultant employed by the hospital found that the prior approach, which relied on unit managers to pass along information to their teams, was not leading to greater institutional knowledge about how to avoid medication errors. The new approach involves the production of short videos detailing the issues that led to a specific medication error. The success of the program is difficult to measure, as it is based solely on self-reporting by hospital leaders who seemed to perceive a substantial reduction in medication errors during the eight-month pilot program. The program bears some similarities to how many attorneys approach claims for pharmacy and medication errors, as a narrative story told to the judge and the jury.

MD Anderson Cancer Center ran a pilot program from October 2012 to June 2013. Every month, a team consisting of a nurse, a pharmacist, and a patient safety specialist would review recent medication errors to identify important concerns. They would decide on three events or issues, and another multidisciplinary team would pick one to use in a video. The hospital’s communications department would handle the actual production, including writing a script, shooting and editing the video, and formatting it into a PowerPoint presentation.

Once the hospital administration approved the final video, it would be uploaded to the hospital’s intranet. The hospital’s various department heads and team leaders would be notified of the new video. The leaders would then be responsible for showing the video to their teams. The hospital produced one video a month for eight months. Hospital leaders reportedly accessed the videos more than 3,500 times during that period, and eighty-three percent of them showed the videos during staff meetings. A majority of leaders said in survey responses that the videos were a “very” or “extremely” successful means of communication. The hospital permanently adopted the program, and has expanded it to share other information besides medication errors.

Hospital Allegedly Gives Infant Incorrect Dosage of Medication for Meningitis Treatment

February 6, 2014 | Lebowitz & Mzhen

The parents of an infant allege that a California hospital is responsible for injuries that required their child to go on life support. Hospital staff reportedly administered far more than the prescribed dosage of medication while treating the child for meningitis. Doctors, nurses, pharmacists, and other medical professionals have a very high degree of responsibility to their patients and the public. A catastrophic injury can result from a seemingly simple pharmacy error, such as a misspelled word or a transposed digit that causes a patient to receive far too much, or not nearly enough, of a drug.

According to news sources, the child was born several weeks premature. He was calm and quiet at first, but began to get “fussy” when he reached one month old. A doctor diagnosed him with viral meningitis, an infection of the membranes around the brain and spinal cord that can be debilitating or fatal if not treated promptly. The child’s parents took him to a hospital for treatment.

A physician at the hospital prescribed an antiviral medication called Acyclovir. After the drug was administered, the hospital pharmacist reportedly told the family that the child had accidentally received about ten times the prescribed amount. The child’s heart stopped several hours later, and his brain started swelling. According to the most recent reporting, he had some brain activity but required the use of a ventilator. The child’s father said that hospital staff told him there was not much more they could do for the child, who was by then six weeks old. One possible option, as described by the press, was for the hospital to provide a ventilator the child could use at home.

Consulting Pharmacist Owed No Duty of Care to Nursing Home Resident Injured Due to Nurse’s Transcription Error

January 30, 2014 | Lebowitz & Mzhen

In order to recover damages for injuries caused by a pharmacy error, a plaintiff must prove that the defendant breached a duty of care that it owed to the injured person. A state appellate court ruled that the husband of a nursing home patient who died due to a medication error could not recover damages from a third-party pharmacy services company or the consulting pharmacist. Thompson v. Potter, 268 P.3d 57 (N.M. App. 2011). The patient’s death, according to the plaintiff’s complaint, was caused by a nurse’s transcription error that resulted in an incorrect medication dose. The court held that the defendants had no authority or control over the nurse, and that they therefore did not breach a duty of care directly to the decedent. With no duty of care, they could not be held liable for negligence or malpractice.

The patient was admitted to a long-term nursing care facility in Alamogordo, New Mexico in February 2004. Her doctor diagnosed her with early dementia and prescribed Ativan, an anti-anxiety medication, to manage her agitation and prevent seizures associated with dementia. The doctor instructed the staff to administer Ativan three times a day and on an as-needed (“PRN”) basis. On January 10, 2005, the doctor told a nurse to discontinue the PRN dose. The nurse transcribed the doctor’s order incorrectly, resulting in written instructions to discontinue the three-times-a-day Ativan dose. The patient missed twenty-one regular doses, suffered a grand mal seizure and a fractured hip on January 17, and later died.

The patient’s husband sued the company contracted by the nursing home to provide pharmacy services and its registered pharmacist, asserting causes of action for breach of contract, negligence, and negligence per se. He did not sue the nursing home, the doctor who prescribed Ativan and changed the dose instructions, or the nurse who made the transcription error. The plaintiff alleged that the sudden withdrawal of Ativan caused his wife’s seizure, and that the injuries sustained due to the seizure caused her death. The defendants breached a duty of care in their capacity as providers of pharmacy services, the plaintiff claimed. The trial court granted the defendants’ motions for summary judgment on all of the plaintiff’s claims.

Similar Drug Names Can Cause Confusion, Catastrophe if Pharmacy Makes an Error

January 15, 2014 | Lebowitz & Mzhen

Confusion between two similarly-named drugs can be harmful or even fatal if the error is not detected quickly. An error could result from any number of circumstances, such as a pharmacist who misreads a doctor’s handwriting or a nurse who accidentally administers the wrong drug. The U.S. Food and Drug Administration has procedures for comparing new drug applications to existing drugs, but this does not guard against confusion regarding drugs that are already on the market. A pharmacy journal published an account last year of one such medication error at an oncology clinic, which fortunately did not result in any complications for the patient who received the wrong medication. A version of the drug she received, however, has been implicated in numerous injuries and lawsuits.

The journal Hospital Pharmacy included an account in its June 2013 issue of a fourteen year-old girl diagnosed with acute promyelotic leukemia (APL) who received the wrong medication for about four months. APL, according to the authors, can quickly turn fatal and requires immediate treatment. Her doctors prescribed an oral dose of trentinoin, a vitamin A derivative commonly prescribed in a topical form under the name Retin-A to treat and prevent acne. It is administered orally in 10-miligram capsules to treat APL. The same basic effect that treats acne can also fight cancer cells.

After completing a course of treatment, the patient returned to the hospital about a month later. Her doctors decided to do several rounds of outpatient intravenous chemotherapy and continue the oral trentinoin. A nurse in the oncology clinic, possibly unfamiliar with the drug, instead called in a prescription for isotrentinoin under the brand name Claravis. While similar to trentinoin, isotrentinoin is primarily used to treat severe acne. It was formerly marketed as Accutane, but the manufacturer discontinued the brand in 2009, allegedly in part because of lawsuits claiming harmful side effects.

Settlement in Hospital Pharmacy Case Demonstrates Weaknesses in Systematic Checks

December 19, 2013 | Lebowitz & Mzhen

Hospital pharmacies, as opposed to retail pharmacies, present unique challenges that can lead to mistakes being made. Those include a much larger amount of patients being served at any given time, more complicated health issues or treatments, different doctors providing coordinated care, and the different medical professionals’ habits in writing prescriptions and delegating tasks to others.

In one case (login required), which eventually prompted a malpractice lawsuit, there was some confusion when a doctor initially wrote a prescription for 10 units, and after deciding to increase the dosage, rather than writing a fresh prescription, he wrote a 2 over the 1, in an attempt to indicate 20.

What happened next, however, demonstrates what can, and does, happen in practice. The nurse practitioner who had walked in as the doctor was writing the prescription, did not know what dosage the doctor had intended, and when she found it in the patient’s file, had difficulty discerning what the doctor had intended. After conferring with the pharmacist for several minutes, and stating that they both saw a 1 and a 2, they concluded that the prescription must have been for 120 units. The prescription for 120 millimoles was filled for the patient, and the prescription was filled and administered to the patient. The nurse practitioner left, since her shift had ended, and when she returned the next day, the patient had died.

Asthmatic Nearly Dies After Dangerous Drug Administration

May 24, 2013 | Lebowitz & Mzhen

An 87 year old woman suffering an asthma attack was taken to a local hospital in Winnipeg by her granddaughter. The woman’s granddaughter, who brought her to the hospital, thought that the treatment would be routine. What followed, however, was far from it.

The woman reportedly ended up on life support, for then unknown reasons. In fact, the patient ended up on a respirator in the ICU for several days. She was apparently in such grave condition that the hospital recommended removing her from life support. Luckily for the emotionally distraught family, after four days in the ICU, the woman’s condition began to improve.

Two weeks following the incident, an individual from the hospital contacted the woman’s family, and admitted that the hospital had made a mistake in the patient’s medicine.

One of the pills that was administered was a “beta blocker,” which is relevant because these types of drugs are known for potentially causing issues for individuals with asthma or other respiratory conditions. As such, they are typically avoided altogether for use in these patients. The hospital claimed that the medication error was not responsible for the woman’s worsened condition, with one doctor writing in her file that the drug, “may or may not have contributed…” to the woman’s need for life support.

A pharmaceutical expert made a statement regarding the physiological impact of these types of drugs, stating that, “If people have either COPD or asthma, and part of the pathology of these diseases is that the airways are already tight, …use it with extreme caution.”

Utilization of Computer System May Lead to MILLIONS Fewer Medication Errors

March 27, 2013 | Lebowitz & Mzhen

A recent article published in the Pharmacy Times, describes the astounding results of a study regarding the use of computerized provider order entry (CPOE) systems in hospitals. The study determined that as of 2008, the use of such systems has helped to avoid more than 17 million medication errors per year in hospitals nationwide so far.
According to the Institute of Medicine (IOM), hospitalized patients are subject on average to at least one medication error per day, which creates the potential for creating medical complications and lasting injury.
The researchers in the study estimated that as of 2008, around one third of all acute-care hospitals in the United States had begun using these types of systems, but only a little over half of them actually used them regularly. Based on that underlying presumption and other data the researchers collected, they estimated that as of 2008, around 26% of medication orders in acute-care hospitals were processed using the CPOE systems.
The computer systems are believed to reduce the chance of prescription medication error by 48%. Coupled with the degree to which CPOE systems have been adopted in hospitals nationwide, it is estimated that the use of the system has reduced the rate of medication errors by 12.5%. That means 17.4 million fewer medication errors throughout the United States in just one year.

There is a caveat however. The reduced number of errors does not necessarily correlate with less harm to the patient. Additionally, the implementation of the systems allows for new ways of making errors such as when a clinician selects either an incorrect medication or dosage from a pull down menu.

Even though the reduction in the errors was a welcomed achievement, the researchers noted that because there is not a universal use of these computer systems, there is much room for improvement to further reduce the widespread occurrence of medication errors.