Hospital Pharmacy Errors

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.

Pharmacy, Nursing Home Sued After Pharmacy Misfill Leads to Resident’s Death

January 7, 2011 | Lebowitz & Mzhen

In recent news that our Washington D.C. pharmacy error attorneys have been following, a nursing home was fined $12,000 last month, after a pharmacy misfill caused a nursing home resident to receive the incorrect medication for 18 days, leading to her wrongful death.

The Auburn Citizen reports that according to an investigation by the New York State Health Department in March and April of 2009, Geraldine Burke, a 94-year-old resident, was given tablets of a blood pressure medicine and diuretic by three different nurses in the Cayuga County Nursing Home, instead of the thyroid medication she had been prescribed.

The tragic medication error reportedly happened as a result of a pharmacy misfill, where a technician at HealthDirect, a separate division of Kinney Drugs that provides pharmacy services for more than 100 facilities, had filled and shipped the wrong medication for Burke. The two medications reportedly had similar looking names—methimazole and metolazone—a common medication mistake that plagues pharmacies in this country, as our lawyers have reported in a recent blog.

Neither the pharmacy or the nursing home recognized the mistake, and Burke was given 11 doses of Metolazone, the diuretic. The autopsy reportedly found that Burke died from heart issues, that were a result of kidney failure, worsened by the diuretic, along with other conditions. When the facility discovered the medication error after her death, they reported it to the Health Department, where they were fined $12,000. Burke’s family sued Cayuga County for negligence, and in turn Cayuga sued HealthDirect for their pharmacy misfill.

Man Died from Overdose of Fentanyl—Widow Sues Center for Medication Error

January 4, 2011 | Lebowitz & Mzhen

Last year, our Baltimore medication error attorneys reported on two cases involving alleged overdoses of the powerful pain medication Fentanyl—one blog discussed a wrongful death lawsuit, where an 68-year-old died after allegedly receiving an incorrect dosage of the potent pain killer, and another blog discussed an overdose of duragesic pain patches, where a care center staff reportedly failed to follow the doctor’s prescription and wait 72 hours before increasing the pain dosage, which also led to a fatal overdose.

In recent news, the widow of a man from Illinois is suing a local pain treatment center for the wrongful death of her husband, due to a medication error of Fentanyl, administered through a SynchroMedII pump. According to Sue Daniels, her husband Tony was admitted in December 2009 to the Piasa Pain Center and was given an incorrect dosage of Fentanyl, which caused him to overdose from the medication error and led to his death. When Daniels became unresponsive from the overdose, he was transferred to Alton Memorial Hospital. Sue claims that the Fentanyl injections caused him to suffer from severe brain damage and lung injuries. He died two years later.

Sue Daniels accuses the pain center of negligence for administering the lethal dosage of pain medication, and blames the managers of the pain center for failure to properly train the medical staff on how to use the equipment. Alton hospital is also named in the suit for not treating Daniels fast enough after the overdose, and for running the Piasa Pain clinic that reportedly administered prescription drug error. Medtronic is also listed as a defendant for manufacturing a pain pump that is allegedly defective.

Sue Daniels is asking for over $500,000 in damages for medical bills, court costs, pain and suffering.

The opioid fentanyl is a narcotic used for patients who are opioid-tolerant from using another potent narcotic pain medication for a week or more. The opioid-tolerant patients are often prescribed Fentanyl when they need an even stronger narcotic for strong pain relief. Fentanyl is only recommended for patients who are opioid-tolerant, as even the lowest strength fentanyl patch has the ability to cause severe side effects, and even wrongful death, according to the FDA. The FDA does not recommend fentanyl patch usage with patients who are not opioid-tolerant—as the warning stated in 2007.

Healthcare Center Sued for Wrongful Death After Man Dies from Pain Medication Overdose

December 1, 2010 | Lebowitz & Mzhen

In recent news that our Washington D.C. nursing home attorneys have been following, a medication error lawsuit has been filed against a local hospital in Salt Lake City, after a patient died from receiving an alleged overdose of a potent pain medication.

According to Deseret News, Clarence Burton was admitted to Woodland Care Center on August 1, 2008, to be supervised by nurses while he underwent radiation and chemotherapy treatment at St. Mark’s Hospital. Burton was reportedly fighting bone cancer, and had been prescribed the brand name pain medication patches Duragesic, containing the strong medication fentanyl to help him deal with the pain.

The lawsuit alleges that the care center staff members made a grave medication mistake when they failed to follow the doctor’s prescription, which was to give Burton one 50-milligram pain patch every 72 hours. The manufacturer of Duragesic also advises to wait 72 hours before increasing the pain medication dosage. Instead, the staff allegedly applied three pain medication patches on Burton’s neck, and he was found a few hours later, lying the floor in complete cardiac arrest.

When Woodland was met by the emergency personnel, they were reportedly unable to revive him, and he was taken to the hospital, where he was given another drug to counteract the fentanyl overdose. Burton was later resuscitated, but according to the lawsuit, remained unresponsive, as he had sustained sepsis, renal insufficiency, and elevated liver function as a result of the alleged malpractice. Burton was taken to another care center six days later, where he died on August 9, 2008.

Maryland Hospitals Decrease Medication Error with New Technology

November 18, 2010 | Lebowitz & Mzhen

According to a study that our Baltimore, Maryland attorneys reported on in a recent blog, thirty-five Maryland hospitals increased their median safety over the past ten years, reducing medication error and patient injury with new technology.

In Maryland’s Peninsula Regional Medical Center, the hospital is reportedly improving the tracking of patient records and the prevention of complications with drugs that can lead to medication errors, when medication is improperly administered, through technology. The hospital is reportedly using a barcode system that our Maryland medication error attorneys also discussed in a recent blog, that removes the chance for medication errors by using barcode scanners to ensure that the barcodes on the prescription match the patient’s bracelet wrist-band and the medication, as well as the dosage.

The hospital also uses “Rosie” the Pharmacy Robot, who joined the pharmacy in 1999 and fills 2,500 doses daily from the pharmacy with 100% accuracy. By using barcode technology, Rosie finds a patient’s drug that has been ordered by the physician and then entered by the pharmacist, and prepares the medication with a special barcode for patient delivery. The robot reportedly even notes when the medication stocks are running low and creates new orders electronically.

Other Maryland patient safety initiatives include the use of electronic medical records, Acudose Medication Storage Cabinets, where security codes are used and any drug taken from the cabinet is recorded, and Online Point of Care Wireless Patient Charting. The hospital is reportedly working on eliminating all human error, and continues to invest in new strategies and procedures as well as technology to reach “zero errors” to protect the health and safety of patients.

Study Finds Maryland Hospitals Improve Safety and Health Standards

November 17, 2010 | Lebowitz & Mzhen

A recent study, published in the medical journal, Quality & Safety in Health Care, reportedly found that thirty-five Maryland hospitals showed notable improvements in the safe delivery and administration of drugs to patients in hospitals.

The study was performed on behalf of the Maryland Patient Safety Center, whose aim is to create health care in Maryland that is safer than any other state in the country by reducing adverse medication events, improving patient safety, and by focusing on improving the care systems in Maryland hospitals.

Released in October of last year, the study concluded that when measuring the delivery of medication, the combined Maryland safety scores for these hospitals dealing with acute care rose by almost 10 percent in over two years, reducing occurrences of medication errors.

By comparing safety data on medication and drug use between the years of 2005 and 2007, the authors of the study reported that Maryland hospitals received the highest scores in the packaging of drugs, the standardized distribution of drugs and safe labeling, safe storage of drugs, and keeping chemicals that are hazardous away from drug-preparation and patient areas, to reduce patient injury or harm.

Children’s Hospital Launches Initiative to Prevent Medication Error

November 1, 2010 | Lebowitz & Mzhen

After two children died from medication errors at Seattle Children’s Hospital over a period of 18 months, as our Baltimore, Maryland medication error injury lawyers recently discussed in a blog, the staff of the hospital held a special ‘Zero Errors Initiative’ Patient Safety Day on Saturday, to prevent tragic medication errors like these from happening to children in the future.

According to the Seattle Post Intelligencer, over 550 physicians, staff, pharmacists, and nurses convened at the hospital for special patient safety sessions, focusing on training designed to prevent future incidents of medication and pharmacy errors.

Pat Hagan, the president of Children’s Hospital reportedly stated that these tragedies and the harm that was done to these children by the hospital will never be forgotten. Hagan said this has been a profound tragedy for the families, and for the hospital staff, and that this feeling will propel the hospital to continue to find ways to prevent life-threatening medication errors from happening.

The sessions during the safety training day included topics such as strengthening the safety of verbal orders, standardizing children’s medications located on care units, prescribing, dispensing and administering medications that are high-risk, improving communication between providers when handing off patients, and patient safety training with the use of simulation.

Pharmacy Error Gives Wrong Drug to Premature Babies

October 29, 2010 | Lebowitz & Mzhen

In a blog from earlier this year, our Washington D.C. pharmacy error injury attorneys discussed Dennis Quaid’s high profile lawsuits against Baxter Heathcare Corporation, that were filed after his newborn twins were given a near-fatal overdose of Heparin, a blood thinner. The medication error was allegedly due to a mistake with Baxter’s look-alike labels, and the twins were given 10,000 units of Heparin instead of 10 units of Hep-Lock, originally prescribed to treat a staph infection.

In a recent medication error in Saskatchewan, Canada, four premature infants in the neonatal intensive care unit at Royal University Hospital were prescribed the drug Heparin, the blood thinner used to prevent clots, and were mistakenly given insulin with the brand name Humulin R, and that was reported to have a similar looking label.

The pharmacy mistake was discovered because all infants were in the same unit, and their conditions were reportedly deteriorating in similar ways due to the insulin, which caused them to have dangerously low blood sugar levels. The infants mistakenly received the insulin in their IV infusion instead of Heparin.

In the review of the incident, the mistake was reported to be caused by an over crowded space in the pharmacy, a possible labeling error that was missed during the many safety checks, or an issue of look-alike labels.

Medication Error Reduced By “Scanning” Patients for Electronic Records

October 28, 2010 | Lebowitz & Mzhen

In a related blog, our Baltimore, Maryland medical error attorneys discussed a recent study showing that implementing electronic health records significantly reduces medical and medication error, by integrating various systems across the country with hospitals and medical groups, to create a common platform for sharing patients’ medical records.

Health-care providers at the Tucson Medical Center (TMC) are reportedly achieving great success with a new electronic system using computerized scanning to verify their work. The electronic system is part of a new protocol at the medical center that was launched on June 1, 2010, after a $30 million upgrade to its electronic medical records system. Under the new system, each patient receives a bar code that is printed on a hospital bracelet. In an effort to reduce medication error and patient injury, before health-care providers can administer any medication, or perform any lab tests, the patient’s bracelet must be scanned, similar to a grocery checkout scanner. The medication must then also be scanned, to make sure that both the dosage and medication match the prescription for the patient.

In the preliminary three months of the new protocol, the system reportedly sent out around 1,500 medication error alerts that the health-care providers immediately corrected. Common medication errors like confusing continuous release and sustained release were also remedied, as the computer caught the medication errors after the patient’s bracelet was scanned.

According to Frank Marini, the CEO and vice president at TMC, the medical center implemented the electronic medical records in 2002, but still had paper charts for patients up until this year. Under the new federal health-reform law electronic medical records are a requirement.

Reporting Children’s Medication Errors Can Help in Prevention

October 1, 2010 | Lebowitz & Mzhen

A recent news article reports that medication errors are among the most common mistakes made by healthcare practitioners—and also among the most under reported.

In a tragic medication error from last year, a child at Seattle Children’s Hospital died from a medication error allegedly involving Calcium chloride. The hospital reported its mistakes to the health department and has acknowledged them publicly. Calcium chloride, the medication that reportedly caused the child’s death, is listed on the Institute for Safe Medication Practices’ (ISMP) class of pharmaceuticals as one of the institute’s “high-alert” medications.

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

According to Dr. Allen Vaida, executive vice president of the Institute of Safe Medication Practices (ISMP), acknowledging medication errors and reporting them is the most important step toward prevention. Vaida claims that children are especially vulnerable to drug overdoses in hospitals because of calculation errors that can occur with medications. Nurses must administer the medication dosages according to a child’s body weight and other necessary factors, that can lead to medication mistakes. He claims that in situations like this, it is important to share information about the medication errors that do occur, as reporting them can prevent errors from happening in the future.