Patient Safety

Label Design Shown to Have Effect on Medication Accuracy

April 16, 2015 | Lebowitz & Mzhen

When a person goes to their pharmacy to get a prescription filled, they hope that it is accurate. However, if there is a problem with the prescription—whether it be the dosage, the instructions, or the drug itself—the patient has an opportunity to review the prescription before ingesting the medication. However, this is not the case in the fast-paced environment of emergency rooms.

Medication errors in emergency rooms are frighteningly common and can carry with them devastating results. However, according to one recent article by the Pharmacy Times, a newly released study shows that there may be something that drug manufacturers can do to decrease medication errors in the surgical and emergency room settings.

Label Design and Its Effect on Error Rate

According to the new study cited in the article, several types of intravenous medications had their labels redesigned after having a team of pharmacists, anesthesiologists, and nurse anesthetists suggest changes that make the label more reader-friendly. The researchers then conducted a study using trainees where the trainee would have to select the requested medication in a fast-paced environment. Researchers used a control group that consisted of trainees using the old labels in order to compare the results.

Second Largest Operator of Institutional Pharmacies in U.S. Agrees to Settle Federal Lawsuits for Misusing Drugs

April 9, 2015 | Lebowitz & Mzhen

Recently disclosed federal court filings have revealed settlement agreements between the U.S. Government and PhyAmerica Corp, a Louisville, Kentucky company that is the nation’s second-largest operator of institutional pharmacies. One of the lawsuits focused on the company’s widespread misuse of Depakote, a seizure drug. According to one news source, the complaint alleged the drug was routinely being prescribed to elderly patients off label to treat other ailments that would have been better treated with the approved medications.

According to the article, the company was allegedly encouraging doctors to prescribe the drug to patients off-label because of an agreement with the drug manufacturer that gave the defendant financial kickbacks for prescribing Depakote. These were kickbacks that they would not have gotten for prescribing drugs that were approved to treat the underlying conditions.

The vast majority of the patients being misprescribed the drugs had their care being financed by the federal government through Medicare and didn’t notice the increased costs, although Pharmerica Corp. allegedly helped to defraud the government out of billions of dollars by encouraging the prescription of Depakote off label.

New Report of Pharmacy Errors Points Out Lack of Accountability

January 29, 2015 | Lebowitz & Mzhen

A recent report by one local Canadian news source points out that, despite there being thousands upon thousands of prescription errors in Canada each year, there is little in the way of accountability for pharmacists who make the errors. According to the report, Canada has about 38,000 pharmacists who fill about half a billion prescriptions each year. But the error rate is unknown.

One woman told reporters that she was provided a double dose of her anxiety medication when she went to have her prescription filled. Another woman told her story about how she was not told by her pharmacist that a prescribed anti-seizure medication would interfere with her birth control. She ended up getting pregnant.

Another man was provided blood-pressure medication instead of the anti-inflammatory his doctor prescribed. He was in such pain that he had to take time off from work, and he eventually lost his job of 30 years as a result of the error. Now he is on permanent disability.

Pressure to Fill More Prescriptions Leads to Increased Error-Rate

December 1, 2014 | Lebowitz & Mzhen

Pharmacies are businesses. They exist to make money. When a pharmacy wants to pad the proverbial “bottom line” this usually means cutting corners elsewhere. In a frightening news report out of Houston, reporters spoke to several former pharmacists and pharmacy experts who told them that the public has no idea what is going on and how common pharmacy errors really are.

According to one former pharmacist, recently some pharmacies like CVS have started using “metrics” to track the efficiency of pharmacists, encouraging them to fill more prescriptions per hour. The ultimate goal of these metrics is to allow management to cut back on the cost of staffing, only having the necessary number of pharmacists and pharmacist technicians on the floor at one time.

However, when pharmacies try and walk this fine line, they often push their pharmacists too hard, creating a dangerous situation where errors are much more likely to occur. As one former CVS pharmacist recalls telling his management team, “I kept saying we’re going to hurt a child or hurt a senior citizen.”

Pharmacy Errors on the Rise Nationwide, Take Every Precaution Possible

August 28, 2014 | Lebowitz & Mzhen

From coast to coast, pharmacy errors have been on the rise lately. While some pharmacy errors are harmless, and many are caught before the patient actually ingests the medication, others can result in serious injury or death.

One recent article from a local news source in Oklahoma City discusses the woes they are having in that area of the country with pharmacy errors. The writer of the article actually had a pharmacy provide her with the wrong drug the week she was writing the piece. Luckily, she caught the error before she took the medication, and the pharmacist provided her with an immediate apology and the correct medication.

However, not every time will a patient be so lucky to catch a pharmacist’s error, nor is it a patient’s responsibility to do so. Each year, there are thousands of injuries and deaths caused by medication errors. Many of these medication errors occur at local pharmacies across the country.

Some Hospitals Stepping Up Efforts to Curb Pharmaceutical Errors

August 6, 2014 | Lebowitz & Mzhen

Pharmacy errors are a serious problem in the American healthcare system. With nearly four billion prescriptions nationwide, and only 240,000 pharmacists, the ratio is not a favorable one for the patient looking to get his or her prescription filled. In fact, by some estimates, there are 2.2 to 3.7 million medication-dispensing errors each year. This equates to over 7,000 deaths each year across the country.

Some hospitals are stepping up efforts to help reduce the number of pharmacy errors that occur in their facilities. According to a report by News-Press.com, Lee Memorial Health System in southern Florida has implemented a number of procedures that help with the rising rates of pharmacy errors. Below are a few of the steps the hospital has taken:

Computerized Prescriber Order Entry and Electronic Records ensure that the prescription that the doctor wants to provide to his or her patient is the one that is submitted to the pharmacist.
Bedside Barcode Medication Administration assigns each patient a barcode with all their medical information accessible to nurses and doctors who can scan the code. This helps decrease the chances of a medication mix-up.
Smart Infusion IV Pumps alert medical staff to any improper or excessive dose when they attempt to administer such a dose.
Integrated Care puts pharmacists on the front line with ER doctors to help make the medicine decisions.

Parents Have a Hard Time When Dosing Children’s Medication Because of Metric-System Conversion

July 30, 2014 | Lebowitz & Mzhen

The United States is one of only three countries in the world that does not use the metric system in practice. While the official system of measurement in the States is the metric system, in reality, no one really uses it. However, this can cause a problem when children are given medication by their parents that requires knowledge of the metric system.

In a recent study by Pediatrics, it is shown that about 40% of parents make a mistake—whether it be over- or under-dosing—when converting from the metric system to the American Standard System. The article proposes switching the United States over to the metric system, which would require a complete overhaul.

The article notes that most pharmacies use the standard system when providing dosing instructions. However, the pharmacists themselves use the metric system to dose the medication. This creates the necessity of a “margin of error” that all pharmacists must tolerate. However, such a margin of error can lead to over-dosing, under-dosing, and medication poisoning.

Public University Collaborates with Private Drugstore Chain on New Model of Patient Care

March 26, 2014 | Lebowitz & Mzhen

A national pharmacy chain has partnered with a medical school and a pharmacy school to open a store that will explore a new model for patient care. The “Walgreens at UCSF” store, located on the University of California, San Francisco campus, is reportedly designed to enable extensive communication between pharmacists and patients. Substantial numbers of people in the U.S. take prescription and over-the-counter medications on a daily basis, and medication errors are a significant cause of injuries and deaths. Various hospitals and other medical facilities are trying out different models of care in an effort to reduce the number of medication errors, and the severity of the injuries they may cause, as much as possible.

The central idea behind Walgreens at UCSF, like many other experimental programs, is the importance of communication between patients, physicians, and pharmacists. Few pharmacies are designed with one-on-one pharmaceutical counseling in mind, and pharmacists tend to remain in the back of the store. The store includes a 1,200-square-foot area with numerous private consultation areas, which pharmacists can use to meet with patients. UCSF describes a concierge desk where patients can check prescriptions and set up pharmacist consultations. Pharmacists employed by both the university and Walgreens will work side-by-side. Rather than simply dispensing medications, pharmacists would work with patients to help them understand how to take medications properly, and provide them with a better overall picture of their health.

According to UCSF, citing the Centers for Disease Control and Prevention (CDC), eighty-two percent of people in the U.S. take medication on a daily basis. Twenty-nine percent take at least five medications per day. Medication errors can occur at any stage of the treatment process, with doctors making a prescription error, pharmacies dispensing the wrong medication or wrong dosage, and patients not following the directions for their medication. UCSF cites statistics from the National Consumers League stating that three-fourths of Americans do not always follow medication instructions, while about one-third do not always take prescribed medications at all. Medication errors cause as many as 1.5 million injuries, 700,000 emergency room visits, and 7,000 deaths every year, at a cost of around $3.5 billion.

Study of “Collaborative Pharmaceutical Care” Finds 3/4 Reduction in Hospital Medication Errors

March 19, 2014 | Lebowitz & Mzhen

A new study, conducted in Irish hospitals and published in a British journal, reviewed the effectiveness of a “collaborative” model of managing hospital patients’ medications. The model, known as the Collaborative Pharmaceutical Care in Tallaght Hospital (PACT), involves close involvement of clinical pharmacists in all stages of patient care during their stay in the hospital. The study, which was uncontrolled, found that PACT resulted in a reduction in the rate of medication errors by more than three-fourths.

The study was published in the online edition of the British Medical Journal Quality & Safety on February 6, 2014. The researchers compared the benefits of PACT to “standard ward-based clinical pharmacy,” with a focus on adult hospital patients receiving acute care, who were prescribed at least three medications in the hospital, and who left the hospital alive. The study included 112 patients receiving care based on PACT, and 121 patients receiving standard care. They measured the rates of medication errors and of potentially severe errors per patient.

According to the description provided in the study, the primary goal of PACT is to reduce the rate of medication errors that commonly occur when a patient is transferred between doctors or departments within a hospital, or transferred from one facility or organization to another, by improving the process of “medication reconciliation” (MedRec). This involves comparing a patient’s current medication orders to the medications a patient has been taking in order to prevent omission of a necessary drug, inclusion of an unnecessary or dangerous drug, or incorrect dosages.

Over-Prescribing of Antibiotics May Be Putting Hospital Patients at Risk

March 12, 2014 | Lebowitz & Mzhen

Lebowitz & Mzhen

March 12, 2014

Updated: March 12, 2014 12:59 pm