Pharmacy Error Injury Lawyer Blog

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:

Woman Claims Fred Meyer Pharmacy Error Significantly Reduced Her Chances of Becoming Pregnant

August 7, 2015 | Lebowitz & Mzhen

Earlier last month, an Oregon woman filed a lawsuit against the national supermarket chain Fred Meyer, alleging that an error made in one of the chain’s pharmacies greatly decreased her chances of becoming pregnant. According to a local Oregon news report, the woman is seeking damages in the amount of $680,000 against Fred Meyer.

Evidently, the woman was prescribed the fertility drug clomiphene. However, upon taking the prescription to get filled at the Fred Meyer pharmacy, the woman was provided with a similarly spelled medication instead. Upon taking just a single dose of the medication, the woman began suffering what she explain as “severe bodily injuries,” including “severe pain, shock to her nervous system, sleeplessness, fear, nervousness, nausea, balance issues, altered consciousness,” and a number of other problems. As a result, she had to stop taking the fertility medication that she was prescribed.

In a lawsuit filed by the woman against Fred Meyer, she claims that by providing her with the wrong medication, the Fred Meyer pharmacy greatly decreased her chances of ever becoming pregnant. The lawsuit was just filed in court during the past month, so a final result is not expected for some time.

Mother Catches Pharmacy Error Before Providing Medication to Her Five-Month-Old Son

July 29, 2015 | Lebowitz & Mzhen

Earlier this month in the English county of Kent, a mother of a five-year-old boy discovered that the pharmacist had included a bottle of what was later determined to be methadone. The bottle had a label on it indicating that it was supposed to have been provided to another patient. Thankfully, the mother discarded any of the medication that was in the bottle, and her son was not provided any of the dangerous opioid.

According to one English news source, the woman went to her local pharmacy to pick up her son’s prescription for his acid reflux medication. When she got home, she noticed that there were two bottles in the bag. One was her son’s usual medication and the other a bottle indicating that it contained 70 milliliters of methadone, a dangerous opioid drug used as an alternative to morphine and also to treat heroin addiction.

When the pharmacy was made aware of the mistake, their initial response was that the bottle was empty, so it created no actual health risk. However, the mother told reporters that the bottle was indeed full of a liquid that she dumped down the sink as a precautionary measure. The pharmacy issued the following statement following what they called a “highly unusual incident”:

As Specialty Mail-Order Pharmacies Proliferate, Accuracy Counts

July 22, 2015 | Lebowitz & Mzhen

Over the last decade or so, the number of specialty pharmacies in the industry has greatly increased. According to one industry news report, this is due in part to the fact that drug manufacturers prefer to rely on a specialized pharmacy to assist patients with the administration and use of their drug than to rely on regular retail pharmacies. However, as the article notes, as more and more patients rely on these specialty mail-order pharmacies, the accuracy of these pharmacies becomes critical to patient health.

Most often, specialty pharmacies deal with very expensive medication. In many cases, this medication is provided to the patient in fairly small amounts in order to prevent what pharmacists call stockpiling, or refilling a prescription a few days early and saving the remaining doses. However, while stockpiling may be seen as a negative from the pharmacy’s and drug manufacturer’s point of view, it means that the accuracy of these pharmacies must be spot on, or else patients may miss a dose.

If a pharmacy only sends out enough medication to last a certain amount of time, and there is an error in the shipment, that may mean that a patient does not receive their required medication for several days. In some cases, this can result in serious health consequences. In fact, the article notes that it is not uncommon for a pharmacy to make an error in the quantity of medication that is sent to a patient, leaving them with less than the required amount for a given time period. Most often, a pharmacy will act quickly to remedy this error, but that doesn’t mean that the consequences can always be avoided.

Father of Pharmacy-Error Victim Takes On What He Calls a Flawed System

July 15, 2015 | Lebowitz & Mzhen

Back in 2006, Christopher Jerry lost his daughter when she died in a hospital after being provided an improperly dosed IV prepared by a hospital pharmacist. According to one recent news article, Jerry has since become an advocate to fix the errors he claims are inherent in the flawed system of pharmacies across the nation.

Evidently, back in 2006, Jerry’s daughter was diagnosed with a yolk sac tumor when she was about 18 months old. Her treatment was going well, and the cancer was nearly eradicated. However, during her final session of chemotherapy, she was given improperly dosed medication and passed away. On the day of the error, Jerry claims that the hospital pharmacy was under-staffed, the pharmacy’s computer wasn’t working, and there was a backlog of physicians’ orders waiting to be filled.

Since that day back in 2006, Jerry has collaborated with other advocates in the field to pass legislation in his home state of Ohio as well as several other states that requires a higher level of regulation for pharmacy technicians. At the time of his daughter’s death, anyone with a high school diploma or a GED could become a pharmacy technician and could end up dosing life-saving medication months later.

Hospitals Starting To Use New Technology to Decrease Prescription Errors

July 8, 2015 | Lebowitz & Mzhen

When most people think of prescriptions, they think about their monthly trip to the pharmacy to pick up their medication. However, a large portion of the prescriptions written and filled each year in the United States originate and are delivered in hospitals. Each year, there are thousands of instances when a prescription is delivered in error to a patient at their bedside while in a hospital. For several years now, those involved in the health care industry have been searching for safer ways of delivering medication to patients.

According to a health care industry news source, some hospitals are implementing a new technology when delivering medication to their patients. The technology is called radio frequency identification (RFID), and it is what is used in drive-through toll booths that have become popular in recent years. The technology allows for a “proximity scan” to pick up information that is held in computer chips, called RFID chips. These RFID chips can hold all kinds of information, including a patient’s required prescriptions as well as their frequency and dose.

One of the hospital executives behind the push for the use of RFID chips explained to reporters that when humans are involved, there is always the potential for error. With the increasing use of technology, it is hoped that the instances of prescription drug errors will drop in the coming years.

Pharmacy Owner Charged in Federal Court for Repackaging Returned Drugs

June 22, 2015 | Lebowitz & Mzhen

Earlier this week in Grand Rapids, Michigan, the owner of a pharmacy was sentenced to three years of probation, 200 hours of community service, and a $30,000 fine for his involvement in a drug repackaging scheme. According to one local Michigan news source, the man who was sentenced was not actually involved in the repackaging scheme, but under the law he was held responsible as the former owner and current registered pharmacist on location.

Evidently, the man who was just sentenced sold the pharmacy to another man, Mulder, back in 2008. Although Mulder was the new owner of the pharmacy chain, the defendant in the case stayed on as a registered pharmacist at one of the branches. Since the defendant self-financed the deal, Mulder was to pay the defendant a monthly payment, similar to a mortgage.

As time went on, Mulder had a difficult time paying the defendant back. The monthly payments were lowered, but he still couldn’t afford to pay them. Mulder then got the idea to repackage medication that was sent back from nursing homes and foster homes, although federal regulations required that these drugs be destroyed.

Alert Fatigue Shown To Be a Major Factor in Many Pharmacy Errors, Solutions May Be Coming

June 15, 2015 | Lebowitz & Mzhen

Whenever a pharmacist is filling a prescription, if there is the potential that the medication they are providing to a patient may have an adverse interaction with another medication, should be taken with specific instructions, or is otherwise potentially dangerous, an alert will pop up on the pharmacist’s screen. However, given that most medications are dangerous under some circumstances, and pharmacists can fill hundreds of prescriptions a day, theses alerts tend to bog a busy pharmacist down.

What is Alert Fatigue?

According to a recent industry report, alert fatigue occurs when a pharmacist is so accustomed to seeing an alert pop up that they almost automatically disregard the alert as unimportant. Reasons for dismissing the error vary, but the end result is the same. The patient ends up taking the prescription home and consuming it, leading to a potentially disastrous situation. As one can imagine, alert fatigue is the cause of a substantial number of pharmacy errors, since pharmacists are substituting their own on-the-fly judgment for the tried and true research of medical professionals.

What Can Be Done About Alert Fatigue?

Given that alert fatigue is a real problem in pharmacies across the United States, there has been a concerted effort by some in the industry to address the issue. One potential solution, according to the article discussed above, is the implementation of software that provides more accurate, more specific, and more targeted alerts. These new programs may also provide a “threat-level” for the pharmacists, so they are able to tell how serious an alert really is.