Patient Safety

Dangerous Safeway Pharmacy Mix-up Gives Pregnant Woman Wrong Medication

February 5, 2011 | Lebowitz & Mzhen

In recent news that our pharmacy misfill injury attorneys in Washington, D.C. have been following, a medication error occurred in a local pharmacy, after a pregnant woman in Colorado was mistakenly given the incorrect medication for another patient who had a similar sounding name.

According to KDVR-TV, Mareena Silva, who is six weeks pregnant, went to Safeway to pick up her antibiotics and was mistakenly given the prescription for Maria Silva, containing Methotrexate, a medication reportedly used to treat cancer.

By the time Silva realized the pharmacy misfill, she had already reportedly taken the first pill. Silva reportedly rushed back to Safeway, where the pharmacist recommended that she throw the pill up, as it had been 30 minutes since she took the medication. Her doctor then sent an ambulance to Safeway.

Methotrexate, the drug Silva took due to the prescription mix-up, can reportedly cause birth defects in an unborn baby. The drug is also reportedly used to cause abortions in pregnancies that are troubled. The manufacturer also warns that there have been reported deaths linked to the incorrect administration of this drug.

After picking up what she thought was the antibiotic, the pharmacist reportedly even stated that the prescribed drug was not good for a pregnant woman. What Silva didn’t realize at the time is that the pharmacist was talking about the Methotrexate.

FDA Reports on Fatal Morphine Oral Solution Medication Errors

January 26, 2011 | Lebowitz & Mzhen

According to a recent report from the U.S. Food and Drug Administration (FDA) that our Washington D.C. medication error lawyers have been following, a morphine solution that was approved by the administration last year, has been linked to a series of morphine overdoses and deaths due to medication error—leading federal regulators to issue a warning and initiate a label change to prevent personal injury or death.

The FDA’s recent notification to the health care industry and consumers reported on the overdoses and deaths that have occurred as a result of morphine sulfate oral solution medication errors, most of which are linked to the high potency (100 mg per 5mL) product, where solutions ordered in milligrams (mg) were erroneously mistaken for milliliters (mL) of the drug, causing fatal overdoses.

When milligrams (mg) are misread and confused for milliliters (mL), the patient dosage could reportedly be as high as 20 times stronger than the dosage intended for the patient, which could result in a drug overdose. Other medication mistakes were reportedly caused by confusion in medication dosage, and understanding the morphine concentration in the oral solution.

As our medication mistake attorneys in Baltimore, Maryland have reported in a related blog, according to the Institute of Medicine’s (IOM), 1.5 million people are injured by preventable medication errors every year, with 98,000 annual deaths from medical errors—7,000 of which are due to medication mistakes.

The morphine sulfate oral solution is manufactured by Roxane Laboratories, Inc., and is used to tread moderate to severe chronic and acute pain with patients who are opioid-tolerant. In a blog from this week, our attorneys discussed the danger associated with an incorrect administration of a powerful prescription pain medication and the prevalence of fatal medication overdoses with patients who are opioid-intolerant and are erroneously prescribed these medications.

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.

A Pharmacy’s Guide to Medication Therapy Management

January 6, 2011 | Lebowitz & Mzhen

In a recent blog, our pharmacy misfill error injury attorneys in Baltimore, Maryland discussed the importance of medication therapy management (MTM) check-ups with a pharmacist, to avoid medication error, pharmacy misfill, and potentially dangerous drug mix-ups that can lead to patient injury or even wrongful death.

The goal of an MTM is to get the maximum benefit from a patient’s prescription medication, and to have the opportunity to ask the pharmacist questions, as one would talk with their doctor, to avoid any medication error, possible side effects or problems with single or multiple medications.

People who reportedly benefit from consulting a pharmacist about medication management are:

• Patients taking medication for more than one chronic condition such as diabetes, depression, asthma, or high blood pressure.
• Patients who are taking one drug with potentially risky side effects, such as the blood thinner warfarin, or medication for seizures.

• Patients who have a hard time following a medication schedule, who forget to take their medicine, or skip them because they are experiencing side effects.

When attending an MTM, Family members or care givers are recommended to join the patient, and patients are advised to bring all medication with them, and if diabetic, their blood-glucose meter along as well. An MTM meeting is recommended once a year, unless the patient is prescribed a new medication and experiencing troubling side effects, a possible medication error, or if the patient is having monthly scheduled meetings the pharmacist.

Medication Therapy Management and the Prevention of Medication Error

December 28, 2010 | Lebowitz & Mzhen

According to the American Pharmacists Association (APhA), medication-related events are a massive problem to this country’s public health and well being. As our Baltimore medication error injury attorneys have reported in a related blog, according to the APhA, 1.5 million people are injured by medication errors every year, that cost around $177 billion in personal injury and death, and could be preventable.

Ed Webb, associate executive director of the American College of Clinical Pharmacy, recently stated that prescribed medication is only beneficial if taken correctly, and if medication therapy is not managed well, it can do harm. Webb, along with other experts, recommends medication checkups, known in the business as medication therapy management, or MTM.

As our Baltimore pharmacy error attorneys also discussed recently in a blog, more and more people are being encouraged to make appointments with their pharmacists as well as their doctors to discuss the medications that they take in an effort to prevent medication error, pharmacy misfill or patient injury.

Patients reportedly often end up saving money when meeting with pharmacists, by switching prescriptions to generic drugs instead of brand-name, or dropping medications that they may no longer need. Other patients are often able to eliminate medication side effects with help from a pharmacist on the best time to take the medication, possibly changing to a different drug, or avoiding a potentially dangerous mix-up of drugs, which can lead to expensive trips to urgent care or emergency rooms and result in personal injury.

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.

Glaxo Pays $750M in Settlement for Violations in Pharmaceutical Drug Manufacturing

November 23, 2010 | Lebowitz & Mzhen

Our Washington D.C. pharmacy error injury attorneys have been following the recent announcement by the U.S. Department of Justice (DOJ) that GlaxoSmithKline (GSK), a research-based pharmaceutical and healthcare company, has agreed to pay the government $750 million in an effort to settle criminal and civil charges alleging that the company sold adulterated drug products to Medicaid and other government health plans, risking the health and safety of consumers.

Cheryl Eckard, a former Quality Assurance Manager for GSK, was reportedly assigned to visit the company’s Cidra, Puerto Rico plant in 2002 with a group of 100 experts and scientists to survey violations cited by the FDA in drug manufacturing. Eckard reportedly discovered major manufacturing and quality testing issues that went beyond the FDA violations, and that could have caused medication error or patient harm.

Deficiencies found in the plant include the release of a topical antibiotic Bacrtoban ointment used to treat skin infections on babies that contained microorganisms, and the production of the Kytril injection, used by cancer patients for nausea that was reportedly not sterile. Deficiencies were also found in the manufacturing of the antidepressant Paxil CR tablets, causing the drug to have the incorrect amounts of active ingredients. Another manufactured drug, Avandamet, a derivative of the drug Avandia, used to treat diabetes, were reportedly found to be superpotent and subpotent.

As the Cidra plant was reportedly GSK’s top manufacturing facility in the world at that time, bringing in $5.5 billion every year, Eckard found that GSK could not assure that they produced contamination-free products that were made in accordance to the drug formula registered with the FDA. She reportedly advised GSK managers to close the plant, and submitted an extensive report to the compliance department at GSK, who claimed her report was unsubstantiated.

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.

Study Shows Barcode eMAR Technology Can Help Reduce Medication Errors

November 3, 2010 | Lebowitz & Mzhen

In a recent blog, our Maryland pharmacy error injury attorneys discussed reducing medication error and patient injury with barcode electronic systems, that link barcodes on the patient’s wrist bracelet with the patient’s electronic records and prescriptions, to ensure that the medication and dosage match the prescription for the patient.

According to a recent study that the Agency of Healthcare Research and Quality (AHRQ) in Rockville, Maryland, has funded, barcode technology, working together with eMAR, the electronic medication administration system, can help reduce medication errors by over 50%. The study was published earlier this year, in the May issue of the New England Journal of Medicine.

Barcode eMAR combines technology to ensure that each patient is given the proper medication with the correct dosage at the right time, in order to prevent medication errors or patient injury. When this combination of technology is used, before administering the medication, the nurses must scan the barcode on the patient’s wrist bracelet, and then scan the medication. If both barcodes don’t match the approved medication, or the timing is not correct for the patient’s next dose, an alert is issued by the system. If the patient’s medication is overdue, warnings are also sent out to the nurses.

In the study, researchers at Boston’s Brigham and Women’s Hospital compared 6,723 medication administrations given on hospital units before the barcode eMAR was introduced with the 7,318 administrations of medication given after the barcode system was introduced.