Pharmacy Error Injury Lawyer Blog

Pharmacists’ Performance Evaluation Metric Acts Like a “Quota System” to Reward Speed Over Precision

October 19, 2015 | Lebowitz & Mzhen

Pharmacies, like other businesses, are operated for profit, and labor is one of the main expenses for a pharmacy. Therefore, a pharmacy that hopes to remain profitable will likely try and provide only enough pharmacists who will be able to fill the prescriptions for the patients who come through the door. Excess pharmacists means the pharmacy is losing money in labor costs.

However, as one recent industry news source points out, the evaluation metric being used by some pharmacies feels a lot like a quota system where pharmacists are pressured into fill prescriptions as quickly as possible. This, of course, could have a detrimental effect on the pharmacist’s accuracy.

Pharmacy Errors Across the Country

Each year, there are an estimated one million medication errors that occur throughout the United States. Of those patients that are provided with an inaccurate medication, about 7,000 will die each year. This makes prescription errors one of the top 10 leading causes of death in the country.

Nurse Administered 70 Flu Shots with the Same Syringe

October 14, 2015 | Lebowitz & Mzhen

Earlier this month in New Jersey, a nurse who arrived at an employer’s office to provide influenza vaccinations to the employees made a “gross oversight” and reused the same syringe for all 70 vaccinations. According to one local news report, the nurse also failed to administer the proper dose of the vaccine to many of the people whom she was supposed to vaccinate.

Evidently, the nurse did change the needles between each patient but not the syringe. The health risk has been classified as “low,” but all employees who were given a vaccine were encouraged to get an HIV and Hepatitis test to make sure they did not contract either of the serious and potentially life-changing diseases.

Employees were also informed to get another flu vaccine, since the nurse improperly dosed each of the vaccines, reducing the vaccine’s effectiveness.

Pharmacist Mistakenly Provides Chemotherapy Drug to Elderly Patient and Then Tries To Cover Up His Mistake

October 7, 2015 | Lebowitz & Mzhen

Earlier this month in New Zealand, a pharmacist was reprimanded by the governing professional board after it was discovered that he made an error in providing a patient with the wrong medication and then tried to cover up his mistake. According to one industry news source, the pharmacist accidentally provided an elderly patient with a chemotherapy drug rather than his prescribed immunosuppressant medication.

Evidently, the elderly patient had recently undergone a kidney transplant and was prescribed an immunosuppressant as a part of his recovery. However, when the man went to fill the prescription, he was provided a chemotherapy drug instead. It was not until three weeks later that the man returned, asking the pharmacist why his pills had changed, that the pharmacist discovered that there may have been an error. He told the patient to stop taking the drug.

Upon investigating the error, the filling pharmacist discovered that he was the one who had filled the prescription. Once he realized that he had made the error, the pharmacist failed to report the error. The Deputy Health and Disability Commissioner, who oversees pharmacists, explained to reporters that the pharmacist should have provided the patient with counseling as well as reported the error. It was not until the pharmacy owner later discovered that the chemotherapy drug supply was depleted that management knew there had been an error. He then made the appropriate report.

FDA Changes Labels on Anti-Bacterial Drug Due to Potential for Easy Mix-Up

September 29, 2015 | Lebowitz & Mzhen

Earlier this month, the Food and Drug Administration (FDA) announced a warning regarding the confusing packaging on the intravenous antibacterial drug Avycaz. According to one industry news source, the announcement was made after there were several reports of errors made in the dosing of the drug to patients. Evidently, the strength of the medication that was listed on the outside of the carton or vial was difficult to decipher for pharmacy personnel.

The confusion apparently arose because of the way that the label listed which substances were actually contained inside each package. Avycaz contains two active ingredients, ceftazidime and avibactam. The previous labels list each separate ingredient and its amount next to the drug’s name. For example Avycaz 2g/.5g means that the drug contained 2g of ceftazidime and .5g of avibactam. The new label will be more descriptive, explaining that the package contains a total of 2.5g of medication, which consists of 2g of ceftazidime and .5g of avibactam.

The Reported Errors

According to the article, there had been three reported errors since the drug’s approval back in February of this year. Two of the errors occurred as the drug was being prepared by the pharmacist, while the third arose due to the confusion in the language on the drug’s packaging. The FDA reported that at least one patient received and ingested a higher-than-prescribed dose, but there had been no adverse effects reported.

New Study Looks at Error Rates in Hospital Pharmacies

September 22, 2015 | Lebowitz & Mzhen

Earlier this month, a study was released in the American Journal of Health Systems Pharmacy that looked at error rates in hospital pharmacies. Specifically, the study considered the link between the number of incoming orders over the course of a given shift and the prescription error rate. Not surprisingly, the results of the study indicated that the busier the pharmacy, the more likely that there would be a pharmacy error made.

The study took place in Houston, Texas, between July 1, 2011 and June 30, 2012. Over the course of the study, over 1.9 million prescriptions were filled by about 50 pharmacists. In total, there were 92 prescription errors recorded.

Prescription Drug Recalls Based on Faulty Childproof Packaging

September 15, 2015 | Lebowitz & Mzhen

Earlier this month, a prescription drug designed and marketed for the treatment of some kinds of cancer, including brain cancer, was recalled because a number of the bottles that contained the drug had faulty caps. According to one industry news report, the caps of approximately 1,100 bottles of the prescription drug, Temozolomide, have the potential to crack, nullifying the childproof nature of the cap.

Evidently, the side effects of the medication are potentially severe, even for adults, and can include respiratory failure, terminated pregnancy, infertility, severe vomiting, and nausea. To ensure that the medication is not ingested by curious children, the U.S. government requires that potentially dangerous drugs like Temozolomide are packaged in childproof packaging. However, for an unknown reason, the caps on a significant number of these bottles were defective.

Specifically, the bottles that may be in danger of having cracked lids were sold between July 2013 and August 2015. The bottles at issue are the five- and 14-count brown bottles with black lettering. Merck, the manufacturer of the drug, has told patients to inspect the caps of their medication and to remove the bottles from the reach of children. In addition, Merck has suggested that all pharmacists who handle bottles of Temozolomide double check to ensure that the caps are in good condition. Of course, any bottle that does have a cracked lid should not be distributed to a patient.

Pharmaceutical Company Named in Lawsuit After Drug Linked to Birth Defects

September 8, 2015 | Lebowitz & Mzhen

Earlier last month, the major pharmaceutical company GlaxoSmithKline was named as a defendant in a lawsuit brought by the parents of a child who was born with a birth defect after his mother took medication produced by the drug manufacturer during pregnancy. According to one national news source, the drug, called Zofran, was initially approved for treating nausea in cancer patients after they received chemotherapy. However, over the years, the drug started to be prescribed to pregnant women looking to lessen the effects of “morning sickness.”

Evidently, the couple filed suit in federal court in Ohio. They allege that the manufacturer marketed the drug for “off label” use to pregnant women back in the 1990s. Shortly after this time, the company allegedly started to get complaints from mothers who took the drug during pregnancy. They were reporting that their babies were being born with heart defects and kidney malformations. In fact, subsequent research has shown that mothers who take Zofran have twice the chance of giving birth to a child with a severe birth defect.

This lawsuit is not unique. In fact, there have been several dozen similar lawsuits brought by parents of children who have been born with severe birth defects after their mothers took Zofran.

Pharmacy Students Participate in Mock Trial to Reduce Future Error Rates

August 28, 2015 | Lebowitz & Mzhen

Earlier this month in Auburn University’s Harrison School of Pharmacy, students and professors put on a mock trial, mimicking a real criminal law trial that alleged criminal negligence on the part of a pharmacist who signed off on an improperly diluted medication that was given to a young child. According to an article by Pharmacy Times, the mock trial is used by administrators to impart the real-world consequences that can result from a pharmacist’s mistake.

The original case arose back in 2006, when a two-year-old girl died as a result of being provided her final chemotherapy session that was improperly diluted. Apparently, rather than having less than 1% salt, the solution contained 23% salt, which ended up being a toxic dose for the two-year-old child. While it was not a pharmacist who prepared the solution, the pharmacist on duty did check the work of the technician who did prepare the solution.

After the error, the girl’s father learned that there were several other problems that contributed to the fatal pharmacy error, including the fact that the pharmacy’s computers were down that day, the pharmacy was understaffed, and there was a backlog of physician orders waiting to be filled. In the real case, the pharmacist was found to be criminally negligent because she inspected and checked off on the work of the technician. She lost her license to practice as a result. The students at the Harrison School of Pharmacy came to the same conclusion, finding that under the facts provided, the pharmacist was acting negligently on the day in question.

Two Local Pharmacies Fined a Total of $43,000 after Regulators Discover a Pattern of Errors

August 21, 2015 | Lebowitz & Mzhen

Earlier this month, two pharmacies in Saskatchewan, Canada, were fined a total of $43,000 after it was discovered that between the two pharmacies, they had misfilled roughly 20 prescriptions over the past few years. According to one local news source, regulators found several errors, including filling prescriptions for medication that was no longer prescribed, providing the wrong doses of a medication, providing pill packets with missing pills, improper labeling, and even two cases where a patient was given “mystery pills” that the pharmacist could not identify even after the error was pointed out.

Apparently, one of the pharmacy’s managers was cited for being an “absentee manager” because she was not present on a daily basis and allowed her name to be used in order for the pharmacy to keep open operations. That pharmacist was fined $8,500 and ordered not to practice in the province for two years. Additional failures were cited, including employing poorly trained assistants, not implementing a tracking system for errors and close calls, several lost or misplaced prescriptions, and failing to provide a pharmacist behind the counter during business hours. The combined effects of these errors resulted in at least 16 patients getting the wrong medication altogether.

In response to these allegations, the pharmacies told reporters that they were going through a time of high staff turnover and had to rely on temporary employees until they were able to hire permanent employees. A spokesperson for the pharmacies indicated that both pharmacies are fully staffed, and every prescription is double-checked by the pharmacist on duty.

Causes and Effects of Pharmacy Errors

August 14, 2015 | Lebowitz & Mzhen

Picking up a prescription at the local pharmacy is something almost everyone has the occasion to do at some point in their life. In fact, many people pick up multiple prescriptions per month. Picking up a prescription that was provided or filled in error seems to many to be one of those situations that “couldn’t happen to me.” However, as a recent article points out, prescription errors are more common than most people think, and they can often have dire consequences if they are not caught immediately.

Common Causes of Prescription Errors

The causes of prescription errors are several, but certain causes appear again and again in studies. The volume of prescriptions that pharmacists and pharmacist technicians must fill on a daily basis results in a high-stress environment where little time is left to double-check one’s work.

A rushed pharmacist is likely working to fill several customers’ orders at a time and may cut corners to save time. However, that type of behavior can increase the risk of providing an incorrect medication to a patient, such as either of the following examples: