Pharmacy Error Injury Lawyer Blog

Mother Sues Pharmacy over 6 Year Old Daughter’s Death in 10x Correct Dosage Case

August 22, 2013 | Lebowitz & Mzhen

A mother is reportedly suing her longtime pharmacy, claiming that a dosage error led to her daughter’s death.

The woman claims that her 6 year old daughter died after taking a dose of morphine 10 times higher than what she was prescribed. The little girl had been taking the liquid painkiller during the course of treatment for sickle cell anemia. Sadly, this tragedy comes on the heels of a report regarding similar errors in the administration of pain medications in young children.

The lawsuit alleges that the young girl died in April 2012, just one day after taking the hyper concentrated dosage. It further claims that the girl’s cause of death was officially ruled “morphine toxicity.”

Report Reveals 36 Serious Incidents of Harm from Medication Related Errors

August 13, 2013 | Lebowitz & Mzhen

Ontario hospitals recently released a new report detailing some 36 incidents that occurred last year where medication-related mistakes led to patients suffering severe harm or even death.

Among the reported incidents, patients were harmed when given incredible overdoses of narcotic painkillers, received the incorrect drug, or were administered an additional (and therefore dangerous) dose.

Of all of the incidents, ten patients died, while the remaining 26 suffered harm so severe that it required life saving interventions to correct, caused a major disability, or led to a shortened life span.

Study Examines Cause of Errors in Opioid Infusion Errors in Children

August 8, 2013 | Lebowitz & Mzhen

Of all of the types of pharmacy and medication errors that are made, some of the most frightening to think about are those that occur with children.

One recent study (registration required) focused on errors made with pain medicine, specifically opioid infusions in children.

The researchers in the study analyzed patient safety and pharmacy data in search of potential critical incidents in patients receiving opioid transfusions over a five year period, from December 2004 to December 2009. Those incidents that scored at least an 8 out of 10 for seriousness were then further investigated in order to conduct an analysis regarding the cause of the error.

The researchers initially identified 166 potential incidents. Out of those, 58 incidents included one (45) or more than one (13) relevant critical incidents. According to the researchers, the most common incident was opioid administration error, which had occurred in 39 of the cases cases (67%).

Fourteen of the incidents were isolated for root cause analysis, which identified 31 root causes. The most frequent and significant ones involved defective preprinted order sheets for the opioid infusions; lack of nursing guidelines for the infusion adjustment rate and weaning off the medication; and inadequate policies and guidelines for monitoring and recording pain, vital signs and arousal. Most significantly, the errors were attributable to an issue with policies/procedures, communication errors, environmental/equipment issues, and inadequate training.

While researchers were not able to study the potential impact of fatigue because the study was retrospective, they did identify one major problem, which involved the transferring of patients between units. The errors were more likely to occur at that point in time because there was no standard set of policies and procedures, increasing the potential likelihood for error.

New Heparin Labels Intended to Reduce Fatal Overdoses

July 25, 2013 | Lebowitz & Mzhen

A recent article in Pharmacy Practice News discussed ways in which updated labeling standards for Heparin Sodium Injection and Heparin Lock Flush Solution may not eradicate the problems associated with overdose completely. One major reason being that some of the older problematic versions of the label remain in pharmacy stocks.

According to information on the relevant organization’s website, the new labeling requirements, which took effect this May, require that the new heparin products clearly indicate the concentration of the medication, followed by how much medication is in each milliliter (mL).

Prior labels stated the per mL amount, with the total container volume appearing elsewhere, thus leading to errors when practitioners mistook the per mL amount as the total volume in the vial. This sort of mistake led to dangerous heparin overdoses.

For example, in one case a patient died due to bleeding in the brain, which occurred as a result of two practitioners mistakenly thinking that a 10-mL vial of heparin held a total of 1,000 units, when each vial actually contained 10,000 units (1,000 units/mL). As a result, they administered 30,000 units to the patient instead of 3,000.

Lawmakers Reverse Decision to Shut Down Pharmacy Blamed for Causing Heart Attack

July 18, 2013 | Lebowitz & Mzhen

Massachusetts lawmakers, and specifically the state’s Board of Registration in Pharmacy, have been under increased scrutiny following the deadly meningitis outbreak that occurred last year.

Prior to the outbreak, the regulators changed course regarding a decision to shut down a Massachusetts pharmacy whose medication error sent a teenager to the emergency room with a heart attack. While they claim to still be investigating, they have yet to take disciplinary action against the responsible pharmacy.

According to state records, in July of 2011 Royal Palm Specialty Pharmacy reportedly accidentally gave a patient thyroid medication that was 1,000 times too concentrated. This devastating error required hospitalization for serious heart complications. The board reportedly only found out about the error after the boy’s mother called to complain, four months later.

According to state documents, instead of supplying 10 microgram capsules of the relevant thyroid medication, the pharmacy apparently provided capsules containing 10,000 micrograms.

After taking the drug, the teenager had to be taken to an emergency room four times and hospitalized twice in August 2011 for heart problems. The symptoms still plague the young man, as he reportedly continues to experience generalized weakness and heart palpitations.

Investigators found that the pharmacy did not report the overdose to the state board, even though they are required to report any errors that lead to death or serious injury within 15 days. A pharmacist for the company says that she did not report the error, because she did not know the extent of the harm to the young man, as she could not get in touch with his mother. The pharmacist has since been reprimanded by the state for the error.

Dangerous Drug Disaster Narrowly Avoided When Vitamin Substituted with Resuscitation Medication

July 11, 2013 | Lebowitz & Mzhen

A Washington woman narrowly avoided a potentially tragic prescription error, when she picked up her usual prescription for the vitamin B12. The label on both the bag and the container even contained the correct name: Cyanocobalamin.

The woman noticed that the color of the actual liquid was different, in addition to the cap on the bottle, but she dismissed her concerns as a potential change in manufacturer.

Then, as usual, the woman’s son came over to help her with the injections. After inspecting the bottle, he asked the woman about it. Fortunately, due to his prior medical training, her son realized that what the woman had was actually not the usual B12 vitamin injection, but rather the dangerous drug atropine, which is used to resuscitate patients in cardiac arrest, among other uses.

The woman had gotten the medication from the military base near her home in Virginia, which sends its prescriptions out to a national center to be filled. It was apparently the national pharmacy that made the error.

The medicine the woman was given could have killed her instantly, or at least led to a heart attack or stroke, among other side effects.

Man Given Opposite of Intended Medication Sues Pharmacy

July 2, 2013 | Lebowitz & Mzhen

A man who went into a pharmacy in order to get pills to keep him awake throughout the day allegedly ended up suffering serious consequences when he was instead given sleeping pills.

The 61 year old man alleges that the mistake caused him to get into minor car accidents, and led to his arrest for driving under the influence of a controlled substance. Luckily for the man, prosecutors later dropped the misdemeanor charges when they decided that he probably was not aware of what he had been taking.

The pharmacy reportedly told police that they had given the man someone else’s prescription. However, the pharmacist also claimed that he told the man that they were sleeping pills, and were only to be taken before bed.

However, the victim in the case maintains that he was given no such warnings, and that he had in fact been instructed to take the medication in the morning. His suit claims that after taking the first pill, that afternoon he began to run some errands, and became drowsy and incoherent. He then pulled his vehicle onto a sidewalk, then backed into another vehicle, before driving to a family member’s home and crashing into their garage door.

Pharmacist’s License Revoked Following Dangerous Drug Mistakes

June 24, 2013 | Lebowitz & Mzhen

A Rhode Island pharmacist, and former state senator, has had his license revoked from the state earlier this month (registration required), following the accidental administration of morphine to two children who received medicine from the pharmacy where he worked.

The Health Director, Michael Fine, ordered the pharmacist’s license to practice revoked, stating the seriousness of the errors, and that a third serious dispensing error of this nature could lead to the potential death of a patient. This was reportedly the second time since 1999 that a pharmacy under the man’s control had made a major labeling error.

According to the order, the man’s license was initially suspended in March 2012, when he acknowledged being the pharmacist in charge of a location where the two mistakes were made. According to the report, two children, aged 11 months and 2 years, were mistakenly dispensed a medicine containing morphine and other serious pain reliever medications, instead of the drug they were supposed to receive in order to treat acid reflux and related conditions. The Health Director stated that this pharmacist has now had three disciplinary proceedings since 1999, and that the similarity and severity of the two incidents “demonstrate an indifference to proper pharmaceutical practice.”

Pennsylvania Patient Safety Organization Releases Staggering Report of Prescription Errors

June 17, 2013 | Lebowitz & Mzhen

According to a report released earlier this month by the Pennsylvania Patient Safety Authority, more than 800 patient medication errors were reported to the agency over a six-month period. According to the report, errors were most likely to occur during the transcribing and administration phases, and occurred the least often during the dispensing and prescribing phases.

Of the 813 reported events, these errors occurred within the following time periods:

353 (43%) administration phase

311 (38%) transcribing phase

98 (12%) prescribing phase

42 (5%) dispensing phase

The three most common medication errors involved: Insulin, Heparin, and Vancomycin (an antibiotic). For those incidents involving a single known medication, almost a third of them were associated with such high-alert medications.

There were many factors involved in the errors. For example, in one case, two separate patients had been prescribed the same medication, but in different doses. The error occurred when the doses were switched.

Another contributing factor was identified as inadequate procedures for verifying the identity of the correct patient, such as with identification bracelets.

Among the reported errors submitted, these were associated with the following:

26% (214) medical-surgical units

22% (180) pharmacy

10% (80) emergency department

3% (25) involved pediatric patients

Despite the various errors, the report stated that none of the incidents resulted in patient harm. While three incidents required temporary intervention, none resulted in prolonged harm or injury.

Electronic Health Records Create New Opportunities for Prescription Errors

June 10, 2013 | Lebowitz & Mzhen

With the advent of new electronic means of managing patient health records, there are now additional ways in which prescription errors can take place.

For example, PCEHR, the Personally Controlled eHealth Record System, was adopted in June 2012 in Australia.It is a health information database designed for use by patients, and according to the National E-Health Transition Authority’s website, “is currently distributed across a wide range of locations including their general practices, hospitals, imaging centres, specialists, and allied health practices.” In essence, the PCEHR is somewhat like an all encompassing electronic health record of a patient. The aim of the program is to make the healthcare system more streamlined and efficient, allowing patients to effectively “share” it with relevant care providers.

A recent article entitled “Pharmacy Error Probable Cause of PCEHR Problem,” which was published appropriately enough in Australia’s eHealth Magazine, details how one woman’s PCEHR somehow received not one but two incorrect prescriptions.

The author reported that she discovered that two prescriptions had been added to her PCEHR. The prescriptions were for drugs that had never been prescribed to her, and were for medical conditions that she did not have.

The drugs were not only written into her record, but apparently were also dispensed by her local pharmacy, even though a notice regarding a consultation at the time they were allegedly dispensed was lacking. The relevant government agency encouraged the woman to inquire with the pharmacy regarding the error, and in doing so the pharmacy cancelled the prescriptions on her patient file. Within a day of the pharmacy’s correction, the woman’s PCEHR was also updated. However, the government told the woman that the same prescription had actually been dispensed on an additional occasion, from a different pharmacy.