Hospital Pharmacy Errors

Lack of Medication Adherence Can Cause Serious Medication Reactions and Injury

May 16, 2011 | Lebowitz & Mzhen

The Institute of Medicine, reports that every year, 1.5 million people are injured by medication-related events. According to an article in the Wall Street Journal (WSJ), that our Baltimore medication error injury attorneys have been following, a recent report from the Agency for Healthcare Research and Quality (AHRQ), found that the number of patients treated in hospitals across the country for illnesses and personal injuries from incorrectly taking medications like sedatives, blood thinners, corticosteroids and other drugs, increased over 50% from 2004 to 2008.

The report also found that over 800,000 U.S. patients were also treated in emergency rooms across the country in medication-related events, stemming from the incorrect usage of antibiotics, insulin, painkillers, and cardiovascular and other drugs. The WSJ looked at some of these individual drugs, to examine how they can cause personal harm or injury if taken incorrectly. According to the report:

• Antibiotics can cause an allergic reaction if taken incorrectly, and can also fail to properly fight infections. Also, when taking antibiotics, patients are generally cautioned to limit sun exposure, as it can cause extreme sunburns.
• Painkillers can cause breathings problems or even death if taken with alcohol or other sedatives or painkillers. OTC products that contain the ingredient acetaminophen can harm the liver if taken with a combination of opioid-acetaminophen drugs.
• Antidepressants and tranquilizers, if taken incorrectly, can lead to panic attacks and suicidal tendencies or actions.
• If taken erroneously, corticosteroids prescribed for asthma, arthritis, transplant patients, ulcerative colitis, and other conditions, can worsen other health conditions, like high blood pressure, blood sugar problems, ulcers, and diabetes, and can also lead to withdrawal if a patient stops taking them suddenly.
• Insulin, if not taken as prescribed, can both increase or reduce a patient’s blood-sugar levels, leading to shock and other health complications.
• If a patient fails to take blood thinners correctly, a high dose that is too high can cause bruising, excessive bleeding, whereas a dose that is too low can cause clotting. Effectiveness of the drug can also be threatened when interacting with other medications.
• Blood pressure drugs can also, if the medication is taken erroneously, cause a spike in blood pressure, and an overdose can cause chest pain, dizziness, shortness of breath, a fast or abnormally slow heartbeat, and can also cause coma.
• Cancer drugs, when taken in error, can cause fever, nausea and vomiting, shortness of breath, diarrhea, cause confusion and fatigue, and when an overdose is taken, can even cause death.

Benefits of Robo Pharmacy Technology in Reducing Prescription Errors

April 1, 2011 | Lebowitz & Mzhen

In a recent Maryland pharmacy error injury lawyer blog entry, our attorneys discussed automated hospital pharmacies the use robots instead of people for tasks that are traditionally manual—in an effort to eliminate medication errors that could cause patient harm or personal injury.

According to the Medical Center of the University of California, San Francisco (UCSF), a hospital that recently implemented an automated hospital pharmacy–the benefits of using an robots instead of people are:

• Robots will help take over the manual medication dispensing tasks traditionally performed by pharmacists and nurses, who will in turn have more time to work with physicians to decide what the best patient drug therapy is, and will have more time to monitor each patient for any clinical responses or adverse reactions to medicine.
• The new pharmacy will provide pharmacy students with a strong training ground in the safe medication distribution systems of the future.
• The pharmacy will also enable the center to study new forms of medication delivery in order to share this groundbreaking information with other hospitals all over the country.

• Out of the 350,000 doses prepared by the robo-pharmacy since 2010, there has not been a single medication error or pharmacy misfill.

According to UCSF, the automated medication dispensing system will allow pharmacists to use their expertise in pharmaceutical care to make sure that each patients receives medication therapy that is catered to their individual needs, in a safe and effective way.

UCSF Employs New Automated Pharmacy to Prevent Pharmacy Error

March 28, 2011 | Lebowitz & Mzhen

In an effort to reduce pharmacy misfills and medication error, the Medical Center of the University of California, San Francisco (UCSF), has recently employed a series of pharmacy robots, according to recent technology news that our Baltimore-based pharmacy misfill attorneys have been following.

In the newly automated hospital pharmacy, UCSF has employed what they consider to be the most comprehensive robots on the market, to prepare and track medications and improve the safety of patients. According to UCSF, since the automated system took over in October 2010, there has not been a single error in the 350,000 medication doses prepared.

This newly automated pharmacy reportedly streamlines the delivery of medication from the prescription directly to the patient, making every step in the medication therapy process safe and effective–from deciding the best drug treatment to patient administration—in order to reduce medication error injury.

How the Robo-Pharmacy Technology works:

• The automated system reportedly prepares medications that are oral and injectable, including chemotherapy drugs that are toxic. The robots are also able to fill IV bags or syringes with medications.
• Once the computers receive a new electronic medication order from an UCSF physician and pharmacist, the robots pick the medication, package the drugs, and dispense doses of the pills that are individualized for each patient.
• The robots assemble medication doses into a thin plastic ring that contains a bar code with all of patients’ medications for a period of 12 hours.
• In the fall of this year, all UCSF Medical Center nurses will start using bar code scanners that read patients’ medication data at their bedsides–a topic our attorneys have discussed in a recent Maryland pharmacy error injury blog–to verify that the patient is being treated with the correct medication.
• A robotic inventory management system also maintains all medication products, with pharmacy warehouses that provide both refrigerated and non-refrigerated drug and supply storage and retrieval.

Hospital Sued for Wrongful Death After Patient Dies from Drug Error

March 22, 2011 | Lebowitz & Mzhen

Our Baltimore-based pharmacy error injury attorneys have been following the recent and tragic news story surrounding a Massachusetts woman, who endured a hospital medication error during a routine hospital stay that reportedly led to her wrongful death.

According to the Boston Globe, Geraldine Oswald was hospitalized in November of last year to clear up an infection that had developed after breaking her shoulder. While staying in the hospital, she reportedly received too much Lepirudin, a blood-thinning drug used to prevent the formation of potentially dangerous blood clots. The medication overdose affected Oswald’s own blood clotting ability, leading to internal bleeding. While in the hospital’s care, Oswald reportedly hemorrhaged for 12 hours before her wrongful death—which the hospital later stated could have been preventable.

The family of Oswald recently stated that they plan to file a wrongful death lawsuit against Massachusetts General Hospital, two nurses and five doctors, claiming that Oswald was supposed to be treated for a common infection, and instead received a blood thinner that was 30 times too high in dosage, and proved to be lethal.

According to the hospital’s report, the on-duty nurse understood the dosage intended for Oswald, but made a medication error while administrating the dose into the I.V. pump. In a meeting with Oswald’s family members after her death, the hospital reportedly stated that the medical error was preventable.

Pharmacy Misfill and Medication Error Prevention

March 8, 2011 | Lebowitz & Mzhen

In a recent Baltimore pharmacy error injury blog, our attorneys discussed the prevalence of pharmacy misfills and prescription drug errors plaguing our nation, with over 1.5 million injuries medication-related events documented by an Institute of Medicine study.

According to a related study discussed by Good Housekeeping magazine, pharmacy errors occur in one out of every five prescriptions. Another study reportedly found that 18 percent of hospital patients are exposed to medication errors. When addressing the problem of pharmacy error and medication mistakes, it is important for the consumer to always check and make sure that the prescription given at the pharmacy is the exact medication prescribed by the doctor.

As our Maryland medication mistake lawyers discussed previously, taking the necessary steps to verify your prescription with the pharmacist before taking medication can prove to be an extremely valuable step in preventing medication error injury. A few pharmacy error prevention tips include:

When receiving a new prescription, always ask the doctor to write down the medical problem associated with the medication, as this could help prevent a pharmacy misfill. Also, when filling a prescription for the first time, it is important to check the prescription label carefully to verify the name, dosage and directions for usage. It is also important to form a relationship with the pharmacist, to discuss the medication directions, as well as any potential allergies or potential medication conflicts that could happen with any other current prescriptions or supplements.

Prescription Pain Medication Error Due to Alleged Drug Theft

February 14, 2011 | Lebowitz & Mzhen

Our Maryland pharmacy error attorneys have been following the recent news story surrounding a prescription drug error that resulted from drug theft, leaving a man without proper pain medication management while undergoing a kidney stone surgery.

According to Fox-9 News, in November of 2010, Larry King checked into Abbot Northwestern Hospital for kidney stone removal surgery. King was reportedly told that the 30-minute operation would be painless. While receiving Fentanyl, a powerful pain relieving medication that according to a recent Baltimore medication error blog is 100 times more powerful than morphine, Sarah May Casareto, the nurse responsible for administrating his surgery pain medication, allegedly stole 300 micrograms from King’s pain dosage in order to take the drugs herself—telling him that he would have to deal with the pain because they couldn’t give him a lot of medication.

Casareto’s prescription pain medication error and drug theft was reportedly discovered by other medical professionals during the operation, after Casareto started exhibiting strange behavior, which allegedly included slurred speech, dropping syringes in the operating room, and falling asleep. When confronted with drug abuse and drug theft, the nurse allegedly still held four unlabeled syringes in her pocket. King has filed a criminal complaint against Casareto, who refused a drug test and immediately resigned after the incident.

As a result of the drug abuse incident, King reportedly felt an extremely high pain level during the surgery, and doctors eventually gave him additional medication to help him through the rest of the operation. He claimed to have filed criminal and possibly a civil case to make sure that other patients don’t experience the same painful medication error that he went through.

Study Finds Frequency of Pain Relieving Medication Errors in Hospitals

February 9, 2011 | Lebowitz & Mzhen

According to a recent study in The Journal of Pain, that our prescription error attorneys based in Rockland, Maryland have been following, medication errors involving pain relievers, or analgesics, including errors made in prescribing, are a substantial contributor to adverse patient events in pain therapy that are preventable.

The study was performed in a hospital facility with 631 beds, and found that the frequency of pain medication errors in hospitals to be 3 per 1,000 prescriptions.

Researchers at the Albany Medical Center in the state of New York reportedly found in previous research that a major number of prescription analgesic errors are preventable, occurring in all stages of the prescription medication usage process, with the primary cause being prescribing errors. The researchers then combed through a large database containing prescribing errors that had been previously prevented by pharmacists in order to pinpoint the main characteristics associated with an increased risk for medication errors.

The overall drug error rate in the study was found to be 2.87 errors per 1,000 orders with a drug prescribing error rate of .63 per 1000 that was potentially serious. Error rates with analgesics were reportedly found to be higher in pediatric orders, a topic discussed in our pharmacy error injury blog from last week.

Keeping Accurate Health Records and Medication Lists Can Prevent Medical Errors

February 8, 2011 | Lebowitz & Mzhen

In a recent blog post, our Prince George’s County pharmacy error attorneys recently discussed the importance for individuals to communicate more effectively with their doctors and pharmacists, to promote the safe and effective use of drug therapy and reduce the risk of medication error.

Every year, according to research by the Institute of Medicine, 1.5 million people are injured by medication-related events. According to the APhA, an important step for medication error prevention is for individuals to carry accurate health records and current lists of prescription medication with them to show doctors and pharmacists that include the medications, the dosage, and the health conditions that the medication is treating.

The APhA claims that patient medication lists reduce the risk of medication duplication, incorrect dosages, pharmacy misfill, and other harmful drug side effects that could come from dangerous interactions. All patient allergies should also be clearly stated on the list, along with any other important information that could prevent medication error by providing emergency staff and pharmacists with important information that could be lifesaving.

The APhA also recommends that patients get to know their pharmacists, as next to doctors, pharmacists are the second most trusted medication experts and providers of healthcare needs.

In an earlier blog post our attorneys suggested other steps to take to reduce the risk of medication error injuries from pharmacy misfill or error:

Study Finds Small Doses of Drugs From Syringes Could Cause Medication Error in Children

February 4, 2011 | Lebowitz & Mzhen

As our Baltimore County pharmacy error attorneys discussed in a recent blog, according to a recent study by the Agency for Healthcare Research and Quality (AHRQ), medical errors are a leading cause of personal injury and death in this country, and rates for possible adverse drug events were three times higher with children than adults in hospitals, with an even higher rate for infants in intensive care units.

In a new study, published in the Canadian Medical Association Journal, a report found that preparing small medication dosages from syringes for infants and children can be dangerously inaccurate and cause medication dosing errors.

According to the report, in administering potent drugs to young patients, small doses are often prepared from medication stock of less than 0.1 milliliter (mL) in size, but the current equipment used to administer the drug does not allow for the correct and accurate measuring of drug volumes that are less than 0.1 mL.

Dr. Christopher Parshuram, the author of the study, who works in the University of Toronto’s Department of Pediatrics and directs the University of Toronto Center for Patient Safety’s Pediatric Patient Safety Research, stated that medications regularly requiring small doses include narcotics and sedatives that are extremely powerful, such as morphine and fentanyl—both drugs that as our Maryland medication error attorneys have reported in a recent blog, have a high-risk for medication mistakes which could lead to patient injury or wrongful death.

ISMP—Prescribing Fentanyl Pain Medication for Short-Term Pain Be Deadly

January 25, 2011 | Lebowitz & Mzhen

In a recent blog, our Baltimore County pharmacy misfill attorneys discussed the prevalence of medication error cases resulting from the incorrect administration of the strong pain relieving medication Fentanyl, also called Duragesic—that if used erroneously can lead to a drug overdose and even wrongful death.

According to a recent article by Michael Cohen, president of the Institute for Safe Medication Practices, (ISMP), Fentanyl is around 100 times more powerful than morphine and for that reason should only be prescribed to people with chronic and long-term pain, like cancer patients, who are opiod-tolerant from already taking heavy prescription narcotics, or opioids, for one week or longer. As Cohen describes, Fentanyl is effective for three days, keeping patients with long-term pain from having to medicate repeatedly during the day.

As our Baltimore, Maryland medication error attorneys reported in a related blog, Fentanyl should only be used with patients who are opioid-tolerant because even the lowest strength Fentanyl patches have the ability to cause major side effects, like breathing difficulties, which can lead to wrongful death. According to the 2007 FDA warning, the Fentanyl patch should not be used with patients who are not opioid-tolerant.

Cohen explains that patients who are opioid tolerant and tolerant of other prescription pain medications have less of a chance of experiencing breathing difficulty when using a Fentanyl patch that is properly prescribed, as stopped breathing is often what kills patients in an overdose. According to Cohen, the big medication mistake currently being made by doctors is using Fentanyl to treat pain post-surgery pain, called acute postoperative pain, which should be treated by using other painkillers.

The ISMP has reportedly been receiving fatality reports since the drug has been introduced, but September of last year proved to be a devastating month for Fentanyl medication overdoses, as three tragic deaths occurred after patients were given Fentanyl by their doctors erroneously, with doses that were too high, at 50mcg/hour.