Patient Safety

Medication Error Causes Death in Washington State Hospital

September 30, 2010 | Lebowitz & Mzhen

In recent news, our Baltimore, Maryland medication error attorneys have been following the story of a recent tragedy, resulting in the death of a patient who went to the hospital for outpatient shoulder surgery, and died shortly after, due to a medication error.

According to the Seattle Post-Intelligencer, Gary William Clezie went to Yakima Regional Medical & Cardiac Center in February 2009, for a simple outpatient arthroscopic shoulder surgery. A few hours after the surgery, Clezie reportedly suffered from brain damage, as a result of an alleged medication error, and died two days later, when his family agreed to remove the construction worker from life support.

After the surgery, Clezie received Dilaudid for his pain, a potent opioid drug for pain management. Clezie was given a device that allowed him to medicate as needed, by self-administering the drug. The doctor reportedly ordered that Clezie have a blood oxygen level monitoring device, that would alert the nursing staff if the oxygen in his blood dipped below a specific level—in which case the staff would alert the doctor, remove drug device from Clezie, and make sure that he was given oxygen.

But according to the Post-Intelligencer, Clezie’s blood-oxygen monitoring device was not attached to him, so when his blood oxygen level plummeted below the doctor’s defined level, his doctor was not notified, he was not removed from the drug device, and he was not given oxygen. Clezie stopped breathing and suffered severe brain damage from the error that led the misadministration of the pain medication.

Clezie’s family reportedly filed a complaint with the Department of Health’s licensing division and the Department of Health determined, as a result of the medication error, that there were grounds for a corrective action against Yakima. The Post Intelligencer claims that Clezie is one of thousands who suffer harm, personal injury, or even wrongful death from medical care in Washington hospitals every year.

DEA Fights Prescription Drug Errors and Abuse with National Take-Back Initiative

September 28, 2010 | Lebowitz & Mzhen

In recent pharmacy injury news, that our Baltimore, Maryland attorneys at Lebowitz and Mzhen Personal Injury Lawyers have been interested in, the U.S. Drug Enforcement Agency (DEA) recently held a nationwide prescription drug “take-back” day. The event was designed to curb health hazards and medication errors that can occur when people hold on to expired medications or throw away unwanted drugs.

According to the DEA, prescription drugs in home medicine cabinets are at great risk for misuse, abuse and theft, as reports show that a large majority of prescription medication errors and abuse come from the drug cabinets of friends and families. The initiative was also striving to combat drug abuse with kids, who are reportedly finding old unused drugs in homes, and bringing them to school, or parties to get high—resulting in tragic drug error injury.

Last week in a medication error in Washington State, nine teenagers were hospitalized after taking prescription medications that were found in homes and passed around at a school bus stop. The kids reportedly took painkillers and anti-depressants. In another case in Philadelphia, an 18-year old accidentally overdosed on a pain reliever medication found at home.

The DEA initiative set up around 4,000 “take-back” drop off sites across the country to encourage people to drop off drugs, where no questions were asked. People were encouraged to either remove the medication labels or to cross out personal information before dropping the drugs at the site.

Woman Sues Medical Center for Negligence Over Accidental Reuse of Syringe During Surgery

September 20, 2010 | Lebowitz & Mzhen

In a recent medical malpractice news story that our Washington D.C. medication error attorneys have been following, a patient at a medical center in Pittsburgh was reportedly administered anesthesia before surgery with the wrong syringe—a syringe that had been already used on another patient.

According to WXPI, patient Kimberlee Blocker was at Forbes Regional Hospital to undergo surgery, when the hospital reportedly gave her the wrong dosage of anesthesia, from a syringe that had previously been used on another patient. Blocker claims she was told after the surgery about the medication error, and that another patient’s syringe had accidentally been placed on her tray.

Blocker stated that after the medical mix-up occurred, she had to endure six tough months of hepatitis and HIV tests to determine if the alleged medical mistake with the wrong syringe had infected her with any diseases. She claims to have cried every time she took a test and was forced to wait two-weeks each time, for the results to come back.

Blocker claims that she could have easily died on that table as the medication that was mistakenly administered to her before the surgery was not prescribed for her. She is reportedly suing the hospital for negligence. Although Blocker’s HIV and hepatitis tests came back with negative results, she hopes that this lawsuit will help others from having to undergo this kind of treatment in the future.

Study Reviews Risk Levels Associated with Pharmacy Drug Dispensing

August 26, 2010 | Lebowitz & Mzhen

As Washington D.C. pharmacy error injury lawyers, we have been following recent study results released by the company Centice, that discuss the risk levels associated with drug dispensing processes, and the occurrence of pharmacy errors or misfills.

Centice is a company focused on the chemical verification of dispensed prescription drugs, and has recently published findings from that investigate levels of risk in the dispensing process for prescription drugs from Pharmacy Quality Assurance and Rx Verification Study.

According to the study’s research, after a single pharmacy error in the dispensing process, pharmacists can spend up to fifty hours correcting the dispensing error, or Quality Related Event (QRE).

Centice claimed that when looking at the total prescriptions filled, pharmacy error rates are very small, but when factored into dispensing many prescriptions over a period of time, given average pharmacy filling volumes, any prescription error that leaves the pharmacy can impact customer retention and the financial stability of the pharmacy, and could also lead to potential patient injury or even wrongful death.

ISMP Licenses MEDcounselor Drug Information to Prevent Medication Error

August 16, 2010 | Lebowitz & Mzhen

According to a press release that our Baltimore pharmacy error attorneys have been following, Gold Standard/Elsevier, a drug information and medication management solution developer, has licensed MEDcounselor Drug Information modules to the Institute for Safe Medication Practices (ISMP) for its consumer website, ConsumerMedSafety.org.

The ISMP is certified by the federal government as a non-profit safety organization of physicians, pharmacists and nurses that strive to prevent medication error and adverse drug events. ISMP offers confidentiality and legal protection for patients who submit safety and medication error reports, and claims that Gold Standard’s MEDcounselor modules are a valuable tool to help consumers become more engaged with their health care, and to make more informed medication decisions—which could prevent medication errors, and patient injuries and deaths on a worldwide basis.

The MEDcounselor modules available through ConsumerMedSafety.org include:

• Drug Information: When typing in the first three letters of the name of a drug, patients and consumers have access to medication information like side effects, important usage, and drug interactions for every prescribed prescription drug in the United States. Over-the-counter (OTC) drugs, vitamins, and nutritional supplements are also included in this information.
• MEDcounselor is written to comply with all national standards for Consumer Medication Information (CMI) and is available in both Spanish and English languages to avoid medication error.
• Drug IDentifier: If capsules or tablets become separated from the original package or container, consumers will be able to identify the drugs quickly by entering the imprint or marking that usually appears in the form of numbers. Patients can also select from thirty colors and twenty-five drug tablet/capsule shape choices for identification.
• Drug Interactions: Consumers and patients will be able to access possible drug interactions between prescription drugs, OTC medication, herbal and nutritional supplements, as well as any food intake, caffeine, alcohol and tobacco products that may interfere with the drug. Drug interaction alert include severity ranking that is color-coded for ease of use, and increases the clarity for the user.

Promoting Electronic Prescribing in Physician Practices

August 3, 2010 | Lebowitz & Mzhen

As our attorneys from Lebowitz and Mzhen Personal Injury Lawyers discussed in a recent blog, although e-prescribing usage has increased in recent years, many local doctors claim that the current e-prescribing systems, although helpful for reducing medication errors, can lead to more mistakes in prescribing.

According to Todd Rowland, M.D. and director of medical informatics for Bloomington, Hospital in Indiana, although the majority of electronic health records systems offer electronic prescribing as an option, some still charge a fee to doctors who use the electronic transmissions for prescriptions. In some instances physicians can send the prescriptions by fax for free, but then get charged to send prescriptions electronically. He also said that physicians are on tight time schedules, and systems that are new require additional steps, that are often overlooked.

Rowland also claimed that right now, many e-prescribing systems have unnecessary drug interaction alerts that pop up while a doctor is prescribing. He claims that as doctors have time-sensitive practices, the e-prescribing should provide high quality information, that prevents medication error, but also fits into their practice, without slowing them down.

Last year, the Center for Medicare and Medicaid Services (CMS) promoted the switch to electronic prescribing by paying doctors a bonus for e-prescribing. By 2012, doctors who are not e-prescribing with be financially penalized by the federal government. As we reported in a recent blog, President Obama’s economic stimulus this year included over $19 billion for health information technology, to help doctors and hospitals pay for the cost of electronic medical records systems and to help improve the safety, quality and efficiency of healthcare.

E-prescribing Usage Increases with Doctors, but Not Without Problems

August 2, 2010 | Lebowitz & Mzhen

As our Washington D.C. Pharmacy Error Injury Attorneys reported in a recent blog, physicians who are not prescribing medications electronically, or e-prescribing, by 2012 will be financially penalized by the federal government.

Although the use of electronic prescribing has increased in years, and evidence shows that e-prescribing can reduce pharmacy misfills that can lead to patient injury or even wrongful death, many local doctors reportedly clam that overall acceptance of this important technology is lagging.

According to a study published last week by the Washington-based think tank, the Center for Studying Health System Change, less than one-third of this country’s physicians in office settings, are e-prescribing. The study also revealed that even fewer physicians that were e-prescribing were using the beneficial aspects of the system, like searching for serious drug interactions and using the system to cross reference patient insurance for prescription drug verifications to ensure health plan payment coverage. The study also found that even fewer doctors who used the electronic system would actually prescribe medications electronically, opting to use the fax machine instead for prescription submittal.

The Institute of Medicine (IOM) claims 1.5 million people in this country are injured by preventable medication errors, with nearly 7,000 deaths every year.

USP Advisory Panel Pushes for Prescription Label Standardization

July 29, 2010 | Lebowitz & Mzhen

According to the Institute of Medicine (IOM), the misuse of medication results in over one million adverse drug events every year. In a recent blog, our attorneys discussed the current efforts made by the U.S. Pharmacopeial Convention (USP) to establish a universal standard for prescription drug labels and instructions, by issuing a series of recommendations in order to add more consistency to prescription labeling—to reduce medication errors that can result in personal injury or wrongful death.

The USP is a Maryland-based nonprofit organization that issues standards that are legally enforceable for the quality, strength, and purity of medicines in this country. In 2007, the USP developed the Health Literacy and Prescription Container Labeling Advisory Panel to examine the different ways prescription drug labeling could be improved.

The IOM claims that health literacy affects ninety million adults, who are unable to benefit properly from the health care due to a lack of understanding of drug instructions and information about medication interactions. After the IOM called for new drug label standards, the USP panel recently released recommendations that are based on patient well being, and health literacy—as bad health literacy can cause medication errors, and increase the potential for heath risks and personal injury.

According to Joanne G. Schwartzberg, co-chair of the panel, standardizing the medication labels can markedly improve the health and safety of patients, by providing reliable, simple and straightforward information. The USP panel recommendations cover the appearance, content, format and languages on prescription labels, in an effort to optimize patient understanding, and eliminate medication error and misuse.

Man Sues CVS for Pharmacy Misfill

July 28, 2010 | Lebowitz & Mzhen

As our Baltimore, Maryland pharmacy error injury attorneys reported in a recent blog, pharmacy errors or misfills can happen in every step of a prescription’s path in a pharmacy. Many factors can lead to prescription error, including misunderstanding a doctor’s handwriting, making mistakes with prescription codes or abbreviations, and misreading a patient’s medical conditions or medication list, among others.

In a recent pharmacy mistake lawsuit, filed last month, Charles Stevens, 70, was given a prescription for Lomotil, an anti-diarrhea medicine that he dropped off to be filled at his local CVS Pharmacy in Santa Barbara, CA in 2009. When Stevens picked up his prescription, he was allegedly mistakenly given a prescription for Warfarin Sodium, a medication prescribed for blood-thinning. Stevens was reportedly already taking blood-thinning medication, and after taking the prescription misfill, he suffered major bleeding, and was immediately taken by his wife to the hospital.

Stevens and his wife are reportedly suing CVS for pharmacy negligence, and pharmacy malpractice, claiming that the pharmacy failed to read the prescription correctly, misfilled his medication bottle with incorrect drugs, and failed to properly analyze Stevens’ medication profile, which could have prevented the medication mistake.

CVS reportedly has a patient profile mechanism that is used to protect patients from such dangerous drug errors as well as dangerous drug combinations, or repeat or double-diagnoses. According to Stevens’ attorney, CVS reportedly admitted to the pharmacy mistake and Stevens’ lawyers are asking for over $200,000 in damages.

Forum Guidance Leads FDA to Help Reduce Medication Errors

July 26, 2010 | Lebowitz & Mzhen

According to recent news that our Washington D.C. pharmacy error injury attorneys have been following, the U.S. Food and Drug Administration (FDA) has committed to reduce medication mistakes by publishing a draft guidance by the end of this fiscal year. The FDA states that one third of medication errors, including 30% of errors ending in deaths that are reported to the Institute of Safe Medication Practices (ISMP), may occur as a result of drug labeling and packaging.

The FDA reportedly claimed that medication errors often happen as a result of names that look alike or sound alike, encoded numerals, failure to recognize active ingredients, dangerous medical abbreviations, and name length.

In a FDA workshop last month, Carol Holquist, RPh and director of FDA’s Division of Medication Error Prevention and Analysis reportedly claimed that guidance on these medication mistake issues is an important first step to developing a consensus to form new FDA regulations, which can take around 10-15 years.

The American Society of Health-System Pharmacists (ASHP)’s director of Medication Use Quality Improvement, Bona Benjamin, also reportedly told the workshop group that the ASHP’s 2007 recommendations for the FDA are still current—that human factoring should be applied scientifically to drug packaging and labeling, and barcode verification should be encouraged, as nearly 20% of hospitals are using barcode medication verification.