Pharmacy Errors and Children

AHRQ Tips for Preventing Medical Mistakes with Children

March 30, 2010 | Lebowitz & Mzhen

In yesterday’s blog, our Baltimore, Maryland Medical Mistake Attorneys discussed leading causes of medical mistakes with children in this country, and important ways to prevent medical errors from happening.

According to the Massachusetts College of Pharmacy and Allied Health Sciences, 88% of medication errors involve the wrong dosage or incorrect drug. The Agency for Healthcare Research and Quality (AHRQ), the lead Federal agency that supports research to improve the quality of healthcare, addresses the importance of patient safety and the cause of many medical errors in a recently published press release.

In the press release, the AHRQ addresses the large problem of medical mistakes with children in this country, and gives parents and guardians tips on how to prevent these medical errors from happening with children, to avoid personal injury.

According to the AHRQ:

• Being involved in your child’s healthcare is the most important way to prevent medical errors or pharmacy misfills. The AHRQ stresses that it is extremely important for parents or guardians to take part in every decision that is made regarding the healthcare for a child.

• Make sure that your child’s doctors know every detail regarding the history and statistics (height and weight) of your child, every prescription, all over the counter medications, and any vitamins or dietary or herbal supplements, as well as any known allergies to any medication.

• At least once a year, bring a bag of everything your child is taking and go through each one with the doctor to ensure that there is no problem or conflict with any medication.

• Make sure you can read every prescription that the doctor writes. Double check the name and dosage, or if there is any question, have the doctor re-write the prescription in capital letters, printing the name of the drug and the dosage. If you can’t read the doctor’s handwriting, chances are the pharmacist will not be able to either.

Keeping Children Safe—Eliminating Mistakes from the Children’s Healthcare Industry

March 29, 2010 | Lebowitz & Mzhen

In our last blog, our Maryland Attorneys from Lebowitz and Mzhen Personal Injury Lawyers, discussed a recent pharmacy misfill, where an 8-year old boy received the wrong dosage of a medication that could have caused the child serious personal injury or even wrongful death.

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

The National Coordinating Council for Medication Error Reporting and Prevention, (NCCMERP), estimates that nearly 98,000 people experience death from medical errors that occur in hospitals every year. Medication errors can happen at any point in the healthcare process and system and can result in injury—from miscommunication with doctors, to prescribing the drug, dispensing drugs at the pharmacy, or in the administering or the process of monitoring the drugs.

The AHRQ recommends that single most important way to prevent medical errors from happening to your child, is to be an active participant with the healthcare team that is caring for your child. Research shows that parents who are involved in all aspects and decisions of a child’s care experience better and safer results.

Eight-Year Old Injured After Pharmacy Error and Prescription Misfill

March 22, 2010 | Lebowitz & Mzhen

In a blog from last week, our Maryland Pharmacy Misfill Injury Attorneys discussed a recent case involving a victim of prescription error involving a patient who was given the incorrect dosage of blood thinners and suffered a massive stroke—leading to her wrongful death.

In related news, our lawyers have been following the recent case of an eight-year old boy, who was immediately hospitalized after a pharmacy error resulted in the boy receiving medication that was ten times stronger than his original prescription.

According to an ABC news article, Jessie Jordan, an 8-year old child from Grand Tower, Illinois, was on medication to treat his Attention Deficit Hyperactivity Disorder (ADHD). The doctor reportedly suggested adding a two-milligram dosage Abilify to his medication list—a drug used to help manage depression and schizophrenia in adults, that the doctor felt could improve his moods.

When the pharmacy filled the prescription for Jordan, they reportedly gave him twenty milligrams of Abilify instead of two—ten times more than the prescribed dosage. Jordan’s father claimed that once he began the medication, he experienced shaking that was uncontrollable, his blood pressure went through the roof, and he experienced delirium. He was taken to the hospital, and according to the news report, the extent of the physical damage and personal injury won’t be known for another month or so, until the child can eliminate from the powerful drug in his body.

Understanding the Prescription Drug’s Path through a Pharmacy can Reduce Error

December 28, 2009 | Lebowitz & Mzhen

In a recent study that our Maryland Pharmacy Error Attorneys have been following, USA Today investigated every step of a prescription’s path in a pharmacy—to uncover the potential for medication mistakes with each step of the filling process, that can lead to patient injury or wrongful death.

In the research, USA Today interviewed pharmacy experts and toured two pharmacies, a CVS and Walgreens, to study the six steps of the prescription filling process, and the potential errors that can happen along the way, as well as real cases that have caused actual injuries or death.

Step 1: Prescription received

When the customer drops off the prescription to the technician, or the doctor’s office calls in the prescription, errors can occur if a technician misunderstands a doctor’s handwriting, prescription codes and abbreviations or misunderstands the oral instructions over the phone. In one case, a doctor’s prescription for methadone read “sig 4 tablet BID for chronic pain,” which means “Please label (sig) this drug to say: take 4 tablets twice per day (BID) for chronic pain. The technician typed, “Take 4 tables by mouth as needed for chronic pain.” The patient allegedly died of an overdose of methadone.

Step 2: Prescription entry
A technician then scans the original prescription into the computer and manually enters the patient’s personal data, like name, address, date of birth and phone number, as well as drug information, strength, dosage instructions and quantity. If a technician incorrectly types the prescribed drug dosage, formulation or the patient’s medical condition, history or allergies into the computer, then serious errors can occur, including personal injury. Also if the wrong drug code is chosen in the computer system, it can be mistaken for a similarly named drug. In one instance, a pharmacy was asked to fill a prescription for compazine, an anti-nausea drug, (COM) and accidentally gave the patient a generic substitute for coumadin, a blood thinner (COU).

Childrens’ Doses of Swine Flu Vaccine Recalled in Maryland

December 17, 2009 | Lebowitz & Mzhen

In Maryland news this week, our medical mistake lawyers have been following the recall announcement by Sanofi-Aventis, the vaccine manufacturer of 800,000 doses of H1N1 vaccine for children under the age of three. According to the Washington Post, the flu vaccine has lost potency after being shipped from the factory, and doses are being recalled in Maryland and nationwide.

The recall dosages are single-dose pre-filled syringes containing the vaccine specifically created for children ages 6 to 35 months. It is a voluntary, nationwide recall by Sanofi Pasteur.

During testing at the time of the vaccine’s manufacture, the doses contained 7.5 micrograms of antigen, the recommended dosage used to stimulate immunity in children. But later testing showed degradation of the vaccine, making it less potent than desired. This proved to be the case with four lots of the vaccine, totaling 800,000 doses.

According to the Centers for Disease Control Prevention (CDC), this recall is part of a routine quality assurance program and is non-safety related. Children who received the vaccine do not need to be re-immunized, but with future immunizations, children should be given the proper vaccination dosage. With children who have only received one vaccine dose, they should get the get their scheduled second dose.

Walgreen’s Pharmacy Misfill—Child Given Heart Medication Instead of H1N1 Antiviral Drug

November 27, 2009 | Lebowitz & Mzhen

Our Pharmacy Misfill Attorneys in Maryland have been following the recent news of a dangerous medication mistake made by a Walgreen’s pharmacy, where a child was given heart medication instead of an antiviral drug to treat the H1N1 flu virus.

When Wilma O’Neill picked up the prescription for her daughter earlier this month, she expected to administer an antiviral medication to help her child’s swine flu symptoms. Over the next 24 hours, O’Neill gave her daughter two doses of the Walgreen’s prescription, and only stopped the medication after the drugstore called, claiming that there had been a pharmacy medication mistake, and someone had received the wrong prescription.

O’Neill brought the prescription back to the pharmacy, where they discovered that her daughter had been given the liquid pediatric medication Amiodarone by mistake—a drug used to treat irregular rapid heartbeats. According to Medline Plus, the U.S. National Library of Medicine on-line service, Amiodarone is used to treat and prevent life-threatening abnormal heart rhythms by relaxing overactive heart muscles, and is used only when other medications are not tolerated. The first few doses should reportedly be administered in a hospital setting, as the medication could cause fatal side effects. The child had been given two times the normal dosage of the actual heart medication, which could have resulted in pharmacy error injury.

O’Neill’s daughter was raced to the emergency room, and monitored carefully. Her EKG was initially normal, and then irregular a day later. O’Neill believes that had the mistake not been realized, the outcome could have been much worse, as her daughter was also very sick with the H1N1 virus.

Walgreen’s acknowledged the mistake and apologized for the error. The company didn’t disclose how the error was discovered, but claimed to have numerous safety checks in place in the drugstore to reduce the possibility of human error. In 2007, Walgreen’s was profiled in a the news program “20/20” for making prescription drug errors, after a child was mistakenly given an adult blood-pressure drug by the pharmacy. The child was rushed to the emergency room after weeks of taking the medicine with delirium symptoms and shaking limbs.

Cardiac Medication Dosing Errors Reported Most Commonly With Infants

October 23, 2009 | Lebowitz & Mzhen

As Maryland Medication Mistake Attorneys, we have been following a recent article from Cardiology Today, revealing that cardiac medication mistakes are reported most commonly with infants—in community hospitals, university hospitals, and pharmacies.

The results of a study showed that diuretics and antihypertensive agents are the most commonly reported drugs that are improperly dosed with infants—frequently prescribed by doctors for pediatric patients with heart disease. According to the article, these drugs have the potential for more widespread use because of neonatal care advances, and the increasing incidence of metabolic syndrome and childhood obesity.

Diuretics and antihypertensive agents are considered by many to be safe, because of their frequent use by doctors, but according to the research, it would be much more beneficial for the physicians, clinicians and pharmacists to have accurate information on the assessments of harm rates, and the groups of infant patients who are at particular risk—to prevent serious medical mistake errors and injury with children.

The most harmful error reports came from reported dosing error of the heart condition drugs: nesiritide, calcium channel blockers, milrinone, digozin, and antiarrhythmic agents.

According to the results from voluntary CV medication error reports that were submitted to a medication error database from the years 2003 and 2004, 50% of the total errors reported occurred in children younger than 1 year of age, and 90% of the error reports occurred in infants younger than 6 months of age.

In the 1,424 causes reported, the most frequent causes of medication error or pharmacy misfills were:

• Human error
• Improper dosing
• Missed or double doses
• Misunderstanding of drug orders
• Mathematical errors which include dilutional errors

Pharmacy Errors Harm Children More Than Adults, So Says the Joint Commission

January 9, 2009 | Jack D. Lebowitz

In preparing a recent case for an 8 year child and her parents, I came across an interesting report from The Joint Commission. (The Joint Commission is a private organization that works closely with the Federal Government to evaluate the quality of care being provided by hospitals.) The report indicated that experts within the medical community agree that children are at a higher risk of harm from prescription errors than adults.

The Joint Commission reported that pediatric medication errors occurred more often due to weight-based dosage calculations that are required when prescribing and administering medication to children, and the more frequent use of decimal points in prescriptions for children. The report went on to indicate that medication errors injure children more severely than if the same errors were made to an adult patient.

The Joint Commission gave four reasons why children are more prone to medication errors that result in serious injury:
1. Medications used for children are primarily designed and packaged for adults. Before medications are administered to children, the concentrations must be appropriately diluted according to the child’s weight. These solutions require a number of complicated calculations that significantly increase the possibility of error;
2. Many health care facilities are primarily designed to care for adults and lack personnel adequately trained in pediatric care. The study found that emergency rooms are particularly high-risk environments for children;
3. Young children are unable to physically tolerate medication errors due to under developed immune systems; and

4. Young children cannot communicate the side effects they suffer due to medication errors.

Medication Errors Common in Hospital Outpatient Cancer Clinics

January 7, 2009 | Vadim A. Mzhen

Recently, University of Massachusetts Medical School researchers concluded that medication errors are increasingly common at outpatient cancer clinics across the country. The report reviewed nearly 11,000 prescriptions dispensed at adult and pediatric oncology clinics nationwide. The research published in the Journal of Oncology, found medication errors in 18% of pediatric visits and 7% of adult visits.

The researchers also found that patients made dosage mistakes at home due to poor communication between doctors, pharmacists and the patients. The authors concluded that better communication between oncology clinics and pharmacists would prevent many prescription errors. One of the clinics reviewed in the study utilized an electronic record keeping system. Not surprisingly, the computerized system reduced the frequency of medication errors.

The medication error attorneys at Lebowitz & Mzhen Personal Injury Lawyers suggest that our readers always check with their nurses and physicians prior to receiving any intravenous medication to make sure that the correct drug and dosage are being supplied.