Hospital Pharmacy Errors

Drug Shortages Impact Patient Care at Maryland Hospital

February 5, 2013 | Lebowitz & Mzhen

A nationwide shortage of a wide range of medications, including anesthetics and cancer-treatment drugs, has impacted the level of care at a Maryland hospital, according to a report in the Frederick News-Post. The shortage is affecting patient care all over the country, leading to greater risks for cancer patients, trauma victims, and other patients needing critical care. The situation at Frederick Memorial Hospital (FMH) provides a glimpse into the challenges that countless hospitals are facing. Additionally, a recent medical study showed that, for at least one type of cancer, the medication substituting for the preferred, but scarce, treatment is potentially increasing patients’ risk of relapse. The risks associated with a lack of a needed drug, or the substitution of an inadequate one, has a significant impact on patient safety and hospital liability.

The News-Post reports that FMH is experiencing shortages of about fifty drugs. The hospital’s pharmacy director characterizes twenty of those drugs as “critical.” Most of the drugs in short supply are generics, and while the hospital has reportedly been able to get enough of the scarce drugs to meet its needs, it has had to devise new strategies for patient care when certain drugs are not available. It has also apparently improved communication and cooperation between area hospitals in procuring drugs, with hospitals sharing their supplies when necessary.

Study Shows Impact of Hospital Medication Errors Involving Injectable Drugs

January 22, 2013 | Lebowitz & Mzhen

A recent study examined the impact of injectable medication errors in hospitals, noting the impact of such errors on both patient health and hospital finances. Costs associated with adverse drug events (ADEs) associated with injectable medications can exceed $5 billion per year, the study found, and can affect over 1 million hospitalizations annually. The study identifies some of the drugs most likely to be involved in medication errors, and has some suggestions for improving patient safety.

A medical device company, Becton, Dickinson and Company, commissioned the study in collaboration with an actuarial consulting firm, Milliman, Inc. The study, entitled “National Burden of Preventable Adverse Drug Events Associated with Inpatient Injectable Medications: Healthcare and Medical Professional Liability Costs,” was published in the online edition of the journal American Health & Drug Benefits on December 10, 2012. It involved the actuarial review of data from the years 2009 to 2011 obtained from MEDMARX, an online system for anonymously reporting medical errors, along with hospital data on medications administered via injection, and data on insurance claims through private health plans and Medicare. The goal was to determine the incremental cost, defined as including all costs from the time of a patient’s admission to the hospital and continuing for a period of four months.

Pharmacy and Surgical Errors Lead to Hefty Fines for Hospitals

December 26, 2012 | Lebowitz & Mzhen

The California Department of Public Health recently issued fines for ten hospitals in that state, totaling $785,00 in penalties for medical errors that occurred between 2010 and 2011. Under California state law, hospitals are required to report errors to the state. The state decides the appropriate penalties and announces both the errors and the penalties in an effort to reduce surgical and medication mistakes, according to a recent article in the L.A. Times.

The article describes one of the errors as involving a patient who died after mistakenly being given a blood thinner instead of a procoagulate (having the opposite effect from what the desired medicine would have done). Another of the errors involved a nurse practitioner prescribing a medicine to which the patient was allergic, resulting in the patient’s spending time in the hospital’s intensive care unit.

Many of the hospitals have described measures they have taken to reduce the risk of error. In the case of patient allergies to specific medicines, the hospital apparently re-trained staff on procedures regarding allergies and implemented a new electronic health records system that makes patient information easier to access.

No system can prevent all errors, but publicly fining hospitals for medical and pharmacy errors is absolutely a step in the right direction for preventing these types injuries in the future. With greater awareness of the issues pervasive in medicine and surgery, we can hope that errors will become fewer and fewer. However, as long as there are similarly named medications, or drastically different pills that resemble each other in size, color, or shape, we will still face the risk of pharmacy errors.

Maryland and many other states impose requirements on hospitals similar to those in California. Under Maryland law, hospitals must report any serious errors that affect patients during treatment. In addition to reporting the errors, hospitals must also analyze how and why the error occurred. Unlike California, however, Maryland has traditionally not identified by name the hospitals that report errors.

This difference may have both positive and negative effects. On the one hand, it may encourage higher levels of reporting by allowing for some degree of anonymity. However, hospitals who fail to report may be subject to even harsher sanctions than mere monetary fines, so the costs of being caught failing to report may outweigh any potential benefits. On the other hand, it creates less accountability and allows hospitals with broken systems to remain quietly broken.

In an Effort to Reduce Medication Errors, San Diego Hospital Implements High Tech Program

December 19, 2012 | Lebowitz & Mzhen

There are approximately 1.3 million people in the United States injured by medication errors every year. Since 2000, the U.S. Food and Drug Administration (“FDA”) have received more than 95,000 reports of medication errors. These reports are voluntary, however, and it is believed that the rate of error is actually much higher. Medication errors occur for a number of reasons, including miscommunication of drug orders, poor handwriting, drugs with similar names are confused or packaging is poorly designed, and even confusion of dosing units.

The FDA takes a number of measures to help reduce medication errors, including reviewing drug names, labels, and packaging, as well as analyzing reports of error and creating guidance for the industry. The FDA reviews around 1,400 reports of error per month, analyzing the cause and type of error that in turn helps the agency develop guidance for health care professionals.

In a remarkable effort to reduce these types of error, San Diego’s newest hospital, Palomar Medical Center, located in Escondido, CA, has taken substantial steps to ensure the prescription drug process is as safe as possible. The hospital has implemented a program that requires doctors to place medication orders via a sophisticated computerized system. Often times, an error may begin with the doctor’s initial prescription being incorrect or misunderstood. The system is designed to require doctors to confirm the order and the dosage as well as being for the correct patient — the computerized process is key to ensuring there are no mistakes made in the first crucial step of the doctor ordering the medication.

All of the medications are bar coded. When the nurse is at the point of giving medication to the patient, the bar code helps to once again confirm it is the correct medication, dosage and patient. The nurse will scan the bar code on the medication, the nurse’s own badge is scanned, the patient’s bar code is scanned and the system then confirms “this is the correct medication, patient and dosage that should be given at this time,” essentially giving the nurse a green light to proceed.

Medical Malpractice Lawsuit Alleges that VA Doctors Overprescribed Antipsychotic Medications, Causing Woman’s Suicide: Grese v. United States of America

November 30, 2012 | Lebowitz & Mzhen

A woman’s lawsuit against the federal government alleges that incorrect diagnoses and incorrect dosages certain medications caused her sister’s suicide in 2010. The plaintiff in Grese v. United States is demanding $5 million in damages, claiming that doctors and other medical professionals with the U.S. Department of Veterans Affairs (VA) breached various professional standards of care by continuing to prescribe medications known to have harmful side effects after the decedent had already attempted suicide, and then by dispensing an excessive amount of a particular antipsychotic drug.

The decedent, Kelli Grese, committed suicide on November 12, 2010 by swallowing a large amount of the antipsychotic medication Seroquel. A few weeks before her death, according to the plaintiff’s complaint, doctors had increased her supply of the medication from thirty days to sixty days, and she almost immediately obtained a sixty-day supply. This gave her enough Seroquel to last 120 days under the earlier prescription, and it allegedly enabled her to commit suicide.

According to the Hampton Roads Daily Press, Grese was discharged from the U.S. Navy in 1997, and she began receiving treatment at the Hampton VA Medical Center during the 1990’s, with treatment for mental health issues beginning in 2008. She had diagnoses for post-traumatic stress disorder, depression, substance abuse, and attention-deficit disorder (ADD). The VA hospital treated her with counseling and medication. She received a diagnosis of severe depression in March 2009 after admission to a psychiatric hospital, with a designation as a suicide risk. She reportedly also suffered from paranoid delusions, recurrent psychosis, and major depressive disorder. After her discharge from the psychiatric hospital, the complaint alleges, the VA continued her existing treatment plan despite “obvious and clear deterioration in her psychological functioning.” Complaint at 4.

VA Hospital Ruled Not Liable for Medication Error of Contract Anesthesiologist: Bethel v. US, Court of Appeals

November 18, 2012 | Lebowitz & Mzhen

A lawsuit, Bethel v. United States, sought to hold the federal government liable for a medication error at a Veterans’ Affairs (VA) hospital that allegedly caused a man severe and permanent brain damage. The anesthesiologist directly accused of the error was an employee of a state hospital who, pursuant to a contract between the two institutions, was working at the VA hospital that day. A federal district judge held that the VA was vicariously liable for the anesthesiologist’s negligence even without a direct employer-employee relationship, and ruled for the plaintiffs after a bench trial. The Tenth Circuit Court of Appeals reversed the finding of vicarious liability and remanded the case to the trial court to apportion liability among the other defendants.

David Bethel was admitted to the Veterans Affairs Medical Center (VAMC) in Denver, Colorado on September 10, 2003 for surgery. The anesthesiologist, Dr. Robin Slover, was an employee of the University of Colorado School of Medicine (UCSM) assigned to work at VAMC. A VAMC employee, first-year resident Dr. Nicole McDermott, assisted Slover during the procedure.

Prior to the procedure, Bethel began to complain of difficulty breathing. The court states that it is not clear what drugs, if any, he had received at this point. McDermott and another resident had to restrain him while Slover returned from another room. Slover administered a paralytic drug called Rocuronium and several other drugs in order to render Bethel unconscious. Bethel eventually needed a tracheotomy to allow breathing. He remained in the hospital until January 2004. Cardiac arrest and a lack of oxygen caused a hypoxic-ischemic brain injury, which has rendered him unable to provide for his own needs or care for himself. The trial court eventually concluded that the drug Rocuronium caused Bethel’s operating room symptoms, and that someone gave it to him by mistake after Slover prescribed a different drug.

Appeals Court Affirms Seemingly Low Damage Award in Medication Error Case, Amends Judgment to Add Loss of Consortium Damages: Langley v. American Legion Hospital

November 9, 2012 | Lebowitz & Mzhen

A woman seeking treatment for an allergic reaction to a bee sting alleged in a lawsuit that she suffered severe and ongoing injuries when hospital staff incorrectly administered her medication. After a trial in Langley v. American Legion Hospital, the court awarded her $25,000 in damages, but awarded nothing to her husband for his loss of consortium claim. The plaintiffs appealed, and the appellate court, while affirming the amount of damages awarded to the wife, reversed the trial court’s denial of damages to the husband.

Shirley Langley went to the emergency room at American Legion Hospital in Crowley, Louisiana on December 5, 2007 with a bee sting causing an allergic reaction. After an initial subcutaneous injection of epinephrine seemed successful, she developed a rebound reaction. The ER doctor ordered another subcutaneous dose of epinephrine, but Langley received the dose intravenously. As an expert would later testify, drugs administered intravenously have a much faster and more pronounced effect. Epinephrine is a very powerful stimulant that can cause a significantly increased heart rate and other complications. After receiving the intravenous dose, Langley reportedly complained of a headache, and her blood pressure quickly shot up from 136/55 to 205/129. Her heart rate increased from 101 beats per minute to nearly 190. She spent about eight hours in the Intensive Care Unit receiving treatment for supraventricular tachycardia.

After the incident, Langley allegedly began to experience multiple health complications, including possible heart and nerve damage, and both pain and numbness in her extremities. She claims she experienced recurring nightmares, anxiety, weight loss, and mood swings. She and her husband, Gregory Langley, sued the hospital, claiming damages for her pain and suffering and medical costs, and for his loss of consortium. The parties stipulated that the hospital breached its standard of care, so causation and damages were the only issues at trial. The court awarded the plaintiffs $25,000 in general damages, but nothing for the loss of consortium.

Insurance Company Denies Accidental Death Benefits, Arguing that Man’s Death from Medication Error Was Not an “Accident”: Estate of Paul v. New York Life Insurance Company

September 27, 2012 | Lebowitz & Mzhen

After a nurse’s medication error allegedly caused a man’s death, his executor claimed compensation under the Accidental Death Benefit (ADB) clause of his life insurance policy. The insurance company refused, arguing that the man’s death was not “accidental,” as defined by the policy. The executor sued, claiming in Estate of Paul v. New York Life Insurance Company that the insurer breached its contract with the estate. The trial court granted summary judgment for the defendant, and the New Jersey Appellate Division affirmed its ruling. The case offers a useful glimpse at how insurance companies view injuries caused by medication errors.

Richard Paul, the decedent, resided in a nursing home when he died. He was receiving treatment for multiple chronic illnesses, including chronic obstructive lung disease and chronic heart failure. A nurse at the nursing home accidentally administered another patient’s medication to him on December 27, 2007. The nursing home transferred him to an intensive care unit at a local hospital upon discovering the error, but his condition worsened. He died in the hospital on January 5, 2008.

Jeffrey Paul, Richard Paul’s son and the executor of his estate, retained a board-certified internal medicine specialist, Donald J. Corey, M.D., to review reports relating to Richard Paul. Although the death certificate identified lymphoma as the cause of death, Dr. Corey prepared two reports that challenged this conclusion. The first report said that the medication error had “a direct causative role” in Richard Paul’s death. The second report, completed a few months later, attributed his death to the nurse’s error and noted that Dr. Corey found no evidence of lymphoma recurrence.

Maryland Hospital Patients Possibly Affected by Radiology Technician Suspected in Hepatitis C Outbreak

August 30, 2012 | Lebowitz & Mzhen

The arrest of a radiologic technician in New Hampshire on charges that he allegedly infected at least thirty-one hospital patients with hepatitis C, has led to concerns about similar outbreaks in at least seven other states where he worked in recent years, including Maryland. The technician also has a history of disciplinary actions at hospitals in several states for alleged drug use and theft of medications. The case has led to some discussion about standards and regulations for radiologic technicians and the impact they may have on patient safety.

Police arrested 33 year-old David Kwiatkowski in late July on suspicion of stealing anesthetics from Exeter Hospital in New Hampshire. Furthermore, he allegedly contaminated syringes, which were subsequently used on patients, with the hepatitis C virus. Thirty-one patients at that hospital tested positive for the same strain of the virus as Kwiatkowski. New Hampshire officials have recommended that around 4,700 people in the state undergo testing for hepatitis C. As alleged details of his history have become public, it has raised concerns in multiple states about not only theft of medications, but possible exposure of patients to the disease.

From May 2008 to March 2010, Kwiatkowski reportedly worked at four different hospitals in Maryland. According to the Associated Press, those hospitals are contacting hundreds of former patients each regarding the matter, with as many as 1,750 people possibly affected. Two of the hospitals told the AP that they did not fire Kwiatkowski, nor did his behavior during his employment there raise “red flags.” Hospitals in other states have different reports.

Johns Hopkins Study Recommends Training of Nurse-Pharmacist Teams to Review Patient Drug Regimens, as a Way to Prevent Medication Errors

August 8, 2012 | Lebowitz & Mzhen

Serious complications and injuries can result from discrepancies between the medications patients take at home, the medications they receive in the hospital, and the medications they take home with them. To prevent such medication errors, a recent study out of Johns Hopkins recommends that hospitals train teams of nurses and pharmacists to reconcile patients’ medication lists. Such teams could better ensure that patients receive consistent medications and dosages, at a lower cost to both the hospital and the patient, thus improving overall health and safety for hospital patients.

The Journal of Hospital Medicine published the study, entitled “Nurse-pharmacist collaboration on medication reconciliation prevents potential harm,” in its May/June 2012 issue. The purpose of the study was to test how “medication reconciliation” could help prevent “adverse drug effects” (ADEs). The study involved over five hundred patients at a “1000 bed urban, tertiary care hospital” from January 2008 through March 2009. Nurses would conduct an interview with patients to obtain a home medication list (HML), outlining all medications regularly taken by the patients. Patients often forgot or otherwise omitted some medications during this process, or were unable to remember the name or dosage of a drug. Some patients could only provide a description of the drug’s appearance, and many were not certain what condition a particular drug treated. Discrepancies between the medications a patient was actually taking and those they received during treatment and upon discharge occurred in forty percent of hospital visits, according to the researchers.