Pharmacy Error Injury Lawyer Blog

Watch Out For Pharmacy Errors – They Can Be Fatal

November 30, 2022 | Lebowitz & Mzhen

When it comes to our prescriptions, we count on pharmacies to get it right. Instructions scribbled by doctors on notepads or hurriedly said by nurses and office staff while we check our calendars for follow up appointments or scrutinize our bills are hardly reliable. Instead, checking and double-checking pill bottles or printed pharmacy instructions before consuming prescription medication is often the safeguard patients use to ensure they’re not over or under consuming their prescribed drugs. When these instructions are wrong, the results can be catastrophic.

What Are the Potential Harms of a Medicine Dosing Error?

According to a recent report, a prescription for alirocumab, a drug to prevent cardiovascular events, was marked with erroneous directions. The pharmacy instructed the patient to inject “1 mg,” or one milligram, under the skin every 2 weeks. But the actual instructions were supposed to be injection of one milliliter. The instructed dosage would have been confusing and impossible to measure for a patient. While this error was fortunately realized by the patient due to the difficulty in measuring one milligram, other such errors—like transcribing a number incorrectly—could result in over or under-consumption of medications, which can lead to overdose or prolonged illness.

In this case, the error occurred because the verification by two pharmacists failed to catch the mistake. Some pharmacies do not have processes for typing directions, even though these medications should often be administered in a standardized way. Doctors provide varying instructions, and pharmacies often follow the doctors’ instructions verbatim or close to it, without verifying the units and dosage against standards for the medication. The prescription in question would have also been easier to understand had the pharmacist instructed the patient to inject one entire pen, rather than 1 milliliter or milligram, as the pen was designed to hold one dose. Pharmacies can also employ more checks to ensure patients understand how to use medications, like asking patients to repeat instructions back and confirm dosage.

Woman Receives Wrong Vaccine in COVID Booster Error

November 17, 2022 | Lebowitz & Mzhen

After a long period of lockdown, demand for COVID vaccines and boosters has been high. At times, the demand has exceeded both the supply of vaccines and pharmacies’ capacity to administer them. Unfortunately, when a pharmacy accepts a high volume of patients without increasing its capacity and hiring more staff, it can result in errors and mix-ups. These errors in vaccine administration have the potential to be fatal.

As a recent news article reported, a woman received the incorrect COVID vaccine booster at a Walgreens pharmacy in Rutland, Vermont. The woman received the vaccine after making an appointment for the “newest, most updated” COVID booster. Two days after her appointment, she received a call from the pharmacy informing her they had mistakenly administered an older version of the booster. The pharmacy employee told her she was still protected from COVID; however, the booster would not protect her from the newest strain. Luckily, the woman did not suffer any medical issues from the mix-up. However, given the potential for a more dire mistake, she filed a complaint with Walgreens’ corporate offices. After doing so, she claims she received an indication that other people had also received the wrong vaccine, though Walgreens denies that it happened to anyone else at the Rutland location.

Notably, the Vermont Office of Professional Regulation filed a complaint in June 2022 seeking to revoke or otherwise discipline the licenses of 32 Walgreens stores in the state, including the Rutland pharmacy. In fact, in its complaint, the Office reported that unsafe conditions at the pharmacies have increased the risk of prescription errors, vaccine administration mistakes, and the risk of harm to patients. Allegedly, Walgreens’s vaccine scheduling site had allowed such high volumes of appointments that staff could not keep up with the demand. According to the complaint, these issues resulted in the pharmacy’s inability to safely administer vaccines.

Woman Seeking Cancer Medicine Receives Anti-Cholesterol Medicine from Local Pharmacy in Potentially Devastating Mix-Up

October 27, 2022 | Lebowitz & Mzhen

Patients seeking medical care have certain standards and expectations for what they will receive when getting treatment. When those standards are not met, the consequences can be dire. For patients whose lives are on the line, one small mistake from a doctor, nurse, or pharmacist can have an enormous impact.

Recently, a woman picked up what she thought was cancer medication from her local pharmacy. She took the prescribed pills for two months before realizing that she had actually received anti-cholesterol medication from the pharmacy instead of the medicine she intended to be taking. The woman’s doctor had prescribed her a drug called exemestane, but the pharmacist had failed to check the medication bottle and had given her something called ezetimibe instead.

Apparently, the pharmacists providing the medication failed to properly dispense the prescription. The pharmacy was supposed to have a three-step process for ensuring that each patient’s medicine was what they were expecting to receive: a check when the medicine was selected from the shelf, a second check when the dispensing label was put on the container, and a third check when the prescription was given to the patient.

Covid-19 Vaccine Administration Errors Involving Labeling

October 14, 2022 | Lebowitz & Mzhen

After almost two years since COVID-19 vaccines become available, there are still concerns regarding avoidable administration errors that result from labeling and communication errors. When we walk into a doctor’s office to receive vaccines, we trust that we will receive the correct vaccination. But when administration errors occur for various reasons, it is important that these errors are accurately reported and that steps are taken to prevent these administration errors from happening again.

According to a recent news report, one current problem involves the labeling of the Moderna vials for the primary series for ages 6 to 11 years of age, which are still labeled as “for booster doses only.” Despite the label, these are not used for booster doses. In addition, there are two different Moderna vaccine vials that have a similar dark blue cap, which could result in an error if the vaccines are stored close together. The labeling includes the word “bivalent”, which may be more difficult to see on the Pfizer booster dose for ages 12 years and up, while compared to the Moderna label which may feature the word “bivalent” more clearly on the label. The word “bivalent” is essential to distinguish between the monovalent vaccine.

According to an interview involving the president of the Institute for Safe Medication Practices (ISMP), which was shared by Pharmacy Practice News, ISMP has received messages via Linkedin, phone, and email regarding how the labels appear to be so similar and regarding the difficulty of seeing the word “bivalent.”

New Best Practices Released for Ensuring Medication Safety

September 29, 2022 | Lebowitz & Mzhen

People that regularly take prescription medicine or have received prescription medication in a hospital or clinic setting can appreciate the vital importance of best practices when it comes to receiving medicine. Whether it is at the pharmacy or in the hospital, it is essential to be aware of safety measures that could make a major difference in the care you receive. Every patient deserves peace of mind when it comes to their medications, and to live free of the consequences of medical and pharmaceutical malpractice.

How Common Are Medication Mistakes?

Incorrect or erroneous distribution or application of medications is surprisingly present in the United States. In fact, some sources cite a rate of one in five Americans experiencing a medical error while receiving health treatment. Unfortunately, Maryland is no exception to this trend, and Maryland residents should be aware of emerging best practices in the face of the increased computerization of pharmacies and hospital medication cabinets.

Emerging Best Practices to Reduce Harm

Study Reveals What Happens in Drug Administration Incidents Involving Wrong-Patient Errors

September 10, 2022 | Lebowitz & Mzhen

The process of receiving medication involves a lot of different moving pieces, and as providers complete their various tasks so that a patient may receive their proper medication, medication errors unfortunately can happen at any stage. Medication errors can involve errors in various stages of the process of ordering or delivering medication. For patients who are medically in need of specific medication to help their condition, and for patients who aren’t necessarily in dire need of their medication, but find themselves on the receiving end of a medication error, the consequences can be devastating.

What Can Happen After a Medication Error?

Medication errors can lead to serious injuries and can lead to adverse reactions. Medication errors can range from receiving the wrong dose, the wrong frequency, and the wrong drug, in addition to the wrong-patient medication error. However, when an incident report is filed and labeled as a wrong-patient error in medication administration, what exactly does that entail? It has been particularly unclear if wrong-patient errors for drug administration involves the wrong-patient receiving a medication intended for someone else, or if the intended patient received the wrong drug. A recent and eye-opening study sought to clarify the meaning behind “wrong-patient” errors in drug administration.

A study was recently published in August 2022 on DovePress, which features peer-reviewed journals in science, technology, and medicine. In this study, researchers investigated wrong-patient medication errors in incident reports that were voluntarily reported by medical staff at a university hospital in Japan. Specifically, the study investigated whether the patient or the drug had been incorrectly chosen in drug administration in incident reports that included wrong-patient errors. The results revealed a few things. First, the study included a total of 4,337 incidents that were reported between April 2015 and March 2016 at a particular hospital in Japan, and medication-related incidents were the most prevalent. According to the study, “[o]f the medication-related incidents, the largest number of incidents occurred at the medication administration stage…”. Evaluators determined “that cases where the intended drugs were administered to incorrect patients occurred less frequently than cases where the wrong drugs were administered to the intended patients.” In essence, this means that the study found that there were more mix-ups involving patients who received a different medication than what they were supposed to receive because there was some kind of mix-up with the type of medication administered (the patients were receiving the wrong drugs, versus situations where the right drugs mistakenly go to the wrong patient).

Recent FDA Warning Regarding Autoinjector Devices and Compatibility with Multiple Sclerosis Treatment Drug Product

August 31, 2022 | Lebowitz & Mzhen

In an ever-changing scientific field, as new information and knowledge are gained each day, there may be important updates regarding your medications. For this reason, it is important to stay in touch with your healthcare providers about possible changes. In August 2022, the Food and Drug Administration (FDA) issued a warning to patients, caregivers, and health care professionals regarding autoinjector devices and their compatibility for use across FDA-approved glatiramer acetate injection drug products. Glatiramer acetate injection is used to treat relapsing forms of multiple sclerosis. There are three FDA-approved glatiramer acetate injection drug products on the market currently. These drug products are all available in a single-dose prefilled syringe with an attached needle, and patients can inject glatiramer acetate using only the syringe or by inserting the syringe into an autoinjector. Autoinjectors are medical devices designed to support patient self-injection of medication.

The FDA announcement lays out the three FDA-approved glatiramer acetate injection drug products and its compatible autoinjector device that is optimal for its use. According to the announcement, the drug product titled “Copaxone”, manufactured by Teva Pharmaceuticals is compatible with Autoject 2. The drug product titled “Glatopa”, manufactured by Sandoz, is compatible with the Glatopaject autoinjector device. Finally, the drug product titled “Glatiramer Acetate Injection”, manufactured by Viatris/Mylan, is compatible with WhisperJECT autoinjector device. The FDA has requested that the manufacturers update their labeling to instruct users to confirm that the autoinjector is compatible before using it to inject glatiramer acetate. Overall, patients, caregivers, and health care professionals should be sure to confirm that their autoinjector is compatible, and manufacturers should update their labeling to advise patients as such. Failure to do so can and has resulted in missed and partial doses.

What Happens if Drug Manufacturers Fail to Properly Label?

Drug manufacturers have the responsibility of following the regulations placed on medications by the FDA. The FDA requires that drugs go through testing before they are FDA approved, and manufacturers must comply with medication labeling regulations. Because there are various regulations and laws that may be applicable depending on the jurisdiction, the type of drug, whether the drug is brand-name or generic, etc – it is important to connect with an experienced attorney who can help you navigate your case. If you have suffered injuries as a result of negligent drug manufacturing companies, connect with a lawyer today to discuss the details of your case.

Hospital Safety Grades Equip Patients With Knowledge About Local Facilities

August 14, 2022 | Lebowitz & Mzhen

Having to visit a medical center can be nerve-wracking because there may be a lot of unknowns, including what kind of quality of care you will be provided. Whether a hospital has had multiple pharmacy errors or other dangerous incidents at the hospital can be particularly important for patients and potential future patients to know.

According to a recent news article, a medical center in California faced the risk of losing its Medicare funding after state inspectors uncovered multiple dangerous incidents regarding proper drug distribution. In one incident, an 88-year-old woman was hospitalized for chest pain, and instead of receiving medication for her symptoms, she was mistakenly given two doses of a chemotherapy drug used to treat breast cancer, a condition that family members say she didn’t have. According to the patient’s daughter, a nurse dismissed the daughter’s concern that after being admitted to the medical center, at one point, she could not understand her mother over the phone and thus told the nurse that it sounded as if her mother had suffered from a stroke. Because of this growing concern, the patient’s daughter called the nurse the next day and requested the list of medications that had been prescribed for her mother. The woman died less than a month after being admitted to the medical center. In a confidential report, the state’s public health inspectors stated that the medication error “could potentially cause harm or serious adverse drug reactions to the hospital’s patients.”

In addition, in another incident at the same hospital, a patient with dementia and a history of falls attempted to walk unassisted in his room and tripped over a device. As a result, the patient suffered a fractured hip and was found on the floor by a nurse. According to the article, an alarm designed to prevent such falls by alerting staff when a patient leaves a bed had not been turned on. Doctors decided not to repair the patient’s help because of their belief that the surgery was unlikely to improve his quality of life, and that patient was placed on comfort care and died 7 days after the accident.

Improper Prescriptions and Optimization of Medications

July 31, 2022 | Lebowitz & Mzhen

Medication is by far the most common method for the treatment of diseases, with between 75% to 80% of physician office and hospital outpatient clinic visits involving medication therapy. Annually, about 275,000 people die each year, and roughly $528 billion in medicine is wasted due to poorly managed medications. Doctors, pharmacists, and other health care professionals have a responsibility to protect patients and ensure that every prescription is safe, effective, and appropriate for each patient. A recent article in the Pharmacy Times, authored by the executive director of The Get the Medications Right Institute, highlights some of the major barriers to appropriate prescriptions. Issues range from a lack of transparency to inadequate commitment to team-based care and benefit plan design integration by care providers. These problems can compound, ultimately resulting in dangerous results for patients.

According to the article, one of the consistent themes when it comes to the failure of medical professionals to optimize medications or prescribe the proper medicine is the current siloed approach to treatment. With different treatment providers unable or unwilling to communicate with each other in the current health care environment, cost-saving and comprehensive care are significantly more difficult to achieve.

What Are Steps to Prevent Improper Prescriptions?

The piece outlines five straightforward questions that health care providers, patients, and pharmacists can utilize to prevent improper prescriptions and optimize the impact of medication when it comes to health care. Briefly stated, the steps are to ensure the correct medication, allow patients to ask questions, ensure the proper dose, provide patients with a timeline for taking the medication and explain how patients will know the medication is working.

Pharmacy Errors and Covid-19 Antiviral Drugs

July 10, 2022 | Lebowitz & Mzhen

As the medical industry progresses and new treatments are developed to address novel health concerns, pharmacists and pharmacy employees have a responsibility to keep up to date on the safe practices for dispensing the medications that have been prescribed. With the advent of new antiviral treatments for Covid-19 infection, pharmacy errors have unfortunately occurred. The Institute for Safe Medication Practices, a professional organization for the pharmaceutical industry, recently released a report on the misadministration of an antiviral cocktail that had been effective at battling Covid-19 infection.

According to the industry journal, the antiviral medication cocktail marketed as Paxlovid has shown promise at treating Covid-19 infection, however dispensing mistakes have been noticed at pharmacies nationwide. The largest single issue with the administration of the drug appears when it is being administered to patients with kidney disease. If a patient exhibited moderate kidney disease and was prescribed the drug, a pharmacist was supposed to remove some of the pills from the blister pack to avoid damaging the patient’s kidneys, however, this was not always done. Patients with severe kidney disease should not have been prescribed the drug at all.

What Are the Common Causes of Prescription Errors?

A mixture of poor package design, unclear instructions, and pharmacist negligence has resulted in patients receiving the wrong dosage of the medication, potentially causing harm. According to the report, some patients received their prescription with the wrong pills removed, while others were prescribed the medication while suffering from advanced kidney disease, putting them at serious risk. Although the article does not mention any serious negative patient outcomes as a result of these errors, mistakes like these can be fatal in some instances. When dispensing a new medication that a patient has not taken before, a pharmacy employee has a responsibility to confirm that the patient understands the correct dosage and method of administration before sending them home with a bottle of pills.