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A recent news article reports that medication errors are among the most common mistakes made by healthcare practitioners—and also among the most under reported.

In a tragic medication error from last year, a child at Seattle Children’s Hospital died from a medication error allegedly involving Calcium chloride. The hospital reported its mistakes to the health department and has acknowledged them publicly. Calcium chloride, the medication that reportedly caused the child’s death, is listed on the Institute for Safe Medication Practices’ (ISMP) class of pharmaceuticals as one of the institute’s “high-alert” medications.

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

According to Dr. Allen Vaida, executive vice president of the Institute of Safe Medication Practices (ISMP), acknowledging medication errors and reporting them is the most important step toward prevention. Vaida claims that children are especially vulnerable to drug overdoses in hospitals because of calculation errors that can occur with medications. Nurses must administer the medication dosages according to a child’s body weight and other necessary factors, that can lead to medication mistakes. He claims that in situations like this, it is important to share information about the medication errors that do occur, as reporting them can prevent errors from happening in the future.

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In recent news, our Baltimore, Maryland medication error attorneys have been following the story of a recent tragedy, resulting in the death of a patient who went to the hospital for outpatient shoulder surgery, and died shortly after, due to a medication error.

According to the Seattle Post-Intelligencer, Gary William Clezie went to Yakima Regional Medical & Cardiac Center in February 2009, for a simple outpatient arthroscopic shoulder surgery. A few hours after the surgery, Clezie reportedly suffered from brain damage, as a result of an alleged medication error, and died two days later, when his family agreed to remove the construction worker from life support.

After the surgery, Clezie received Dilaudid for his pain, a potent opioid drug for pain management. Clezie was given a device that allowed him to medicate as needed, by self-administering the drug. The doctor reportedly ordered that Clezie have a blood oxygen level monitoring device, that would alert the nursing staff if the oxygen in his blood dipped below a specific level—in which case the staff would alert the doctor, remove drug device from Clezie, and make sure that he was given oxygen.

But according to the Post-Intelligencer, Clezie’s blood-oxygen monitoring device was not attached to him, so when his blood oxygen level plummeted below the doctor’s defined level, his doctor was not notified, he was not removed from the drug device, and he was not given oxygen. Clezie stopped breathing and suffered severe brain damage from the error that led the misadministration of the pain medication.

Clezie’s family reportedly filed a complaint with the Department of Health’s licensing division and the Department of Health determined, as a result of the medication error, that there were grounds for a corrective action against Yakima. The Post Intelligencer claims that Clezie is one of thousands who suffer harm, personal injury, or even wrongful death from medical care in Washington hospitals every year.

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In recent pharmacy injury news, that our Baltimore, Maryland attorneys at Lebowitz and Mzhen Personal Injury Lawyers have been interested in, the U.S. Drug Enforcement Agency (DEA) recently held a nationwide prescription drug “take-back” day. The event was designed to curb health hazards and medication errors that can occur when people hold on to expired medications or throw away unwanted drugs.

According to the DEA, prescription drugs in home medicine cabinets are at great risk for misuse, abuse and theft, as reports show that a large majority of prescription medication errors and abuse come from the drug cabinets of friends and families. The initiative was also striving to combat drug abuse with kids, who are reportedly finding old unused drugs in homes, and bringing them to school, or parties to get high—resulting in tragic drug error injury.

Last week in a medication error in Washington State, nine teenagers were hospitalized after taking prescription medications that were found in homes and passed around at a school bus stop. The kids reportedly took painkillers and anti-depressants. In another case in Philadelphia, an 18-year old accidentally overdosed on a pain reliever medication found at home.

The DEA initiative set up around 4,000 “take-back” drop off sites across the country to encourage people to drop off drugs, where no questions were asked. People were encouraged to either remove the medication labels or to cross out personal information before dropping the drugs at the site.

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In a recent medical malpractice news story that our Washington D.C. medication error attorneys have been following, a patient at a medical center in Pittsburgh was reportedly administered anesthesia before surgery with the wrong syringe—a syringe that had been already used on another patient.

According to WXPI, patient Kimberlee Blocker was at Forbes Regional Hospital to undergo surgery, when the hospital reportedly gave her the wrong dosage of anesthesia, from a syringe that had previously been used on another patient. Blocker claims she was told after the surgery about the medication error, and that another patient’s syringe had accidentally been placed on her tray.

Blocker stated that after the medical mix-up occurred, she had to endure six tough months of hepatitis and HIV tests to determine if the alleged medical mistake with the wrong syringe had infected her with any diseases. She claims to have cried every time she took a test and was forced to wait two-weeks each time, for the results to come back.

Blocker claims that she could have easily died on that table as the medication that was mistakenly administered to her before the surgery was not prescribed for her. She is reportedly suing the hospital for negligence. Although Blocker’s HIV and hepatitis tests came back with negative results, she hopes that this lawsuit will help others from having to undergo this kind of treatment in the future.

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In a recent news story that our Baltimore, Maryland pharmacy error injury attorneys have been following, a two-year-old child was rushed to the hospital, after a prescription error was made at a Jersey City Walgreen’s pharmacy, while dispensing the boy’s allergy medication prescription.

According to the Jersey Journal, the father of the young boy reportedly went to the Walgreen’s Pharmacy to pick up the prescription for his son’s hydrocortisone prescription, to treat his allergies. The pharmacy gave the father the correct medication for his child, and in addition, the wrong prescription for 10mg of oxycodone, a powerful pain medication that had been filled for a patient who shared the same last name and first initial as the boy.

Crystal Williams, the boy’s mother, reportedly gave her two-year-old child one of the Oxycodone pills, and after ten minutes was alarmed when the child looked dangerously sleepy. Williams then realized the serious pharmacy error that had occurred, after reading the label on prescription bottle—discovering that her child had been given a drug with someone else’s name on it.

Upon discovering the pharmacy error, Williams dialed 911, and rushed her child to the hospital where doctors reportedly gave him shots to keep him alert. A few hours later he was transferred to an intensive care unit at a different hospital. According to Michael Curci, the pharmacy director for LibertyHealth, which operates the Medical Center where the boy was originally taken, an excessive amount of oxycodone can be life threatening, as it can cause respiratory depression and the inability to breathe.

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Our Baltimore, Maryland pharmacy error injury lawyers have been following the results of a recent Consumer Reports Health Poll, that found that 65 percent of most Americans feel that drug makers have too much influence on doctors, and that doctors are too quick to prescribe drugs instead of exploring other non-drug options to manage health conditions. The poll also found that as patients, many Americans have a strong desire to acquire more drug information and safety details to prevent prescription errors in the future.

The Consumer Reports Health Poll found that:

• 45 percent of Americans take at least one prescription drug per day on a regular basis, and on average, they take around four prescription drugs.
• 39 percent of American consumers cut costs on personal healthcare in ways that might be dangerous and could lead to personal injury, with 27 percent failing to comply with drug prescriptions. In an effort to save money, 38 percent of individuals under the age of 65 who don’t have prescription drug coverage, failed to even fill the prescription.
• 87 percent of Americans stated that understanding the safety of a prescription drug was very important, and 79 percent of individuals were concerned about dangerous drug interactions. 78 percent worried about drug side effects.

• 47 percent of Americans said they think that pharmaceutical companies sway doctors’ choice of drug administration for patients based on gifts, and 41 percent of people stated that they think doctors tend to prescribe newer drugs that are more expensive.

According to the Institute of Medicine, at least 1.5 million drug errors occur every year in this country—errors that are preventable. John Santa, M.D. M.P.H., and Consumer Reports Health Ratings Center director, claimed in the study that Americans who are taking multiple drugs considered drug safety and side effects to be a high priority. The poll found that safety information provided in the pharmacy, doctor’s office or hospitals is not always comprehensive enough to prevent medication mistakes or drug error, and needs to be addressed.

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As Washington D.C. pharmacy error injury lawyers, we have been following recent study results released by the company Centice, that discuss the risk levels associated with drug dispensing processes, and the occurrence of pharmacy errors or misfills.

Centice is a company focused on the chemical verification of dispensed prescription drugs, and has recently published findings from that investigate levels of risk in the dispensing process for prescription drugs from Pharmacy Quality Assurance and Rx Verification Study.

According to the study’s research, after a single pharmacy error in the dispensing process, pharmacists can spend up to fifty hours correcting the dispensing error, or Quality Related Event (QRE).

Centice claimed that when looking at the total prescriptions filled, pharmacy error rates are very small, but when factored into dispensing many prescriptions over a period of time, given average pharmacy filling volumes, any prescription error that leaves the pharmacy can impact customer retention and the financial stability of the pharmacy, and could also lead to potential patient injury or even wrongful death.

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Our Hartford pharmacy error attorneys have recently been alerted about a wrongful death lawsuit announced last week involving the incorrect administration of morphine, a topic our Maryland attorneys have been reporting on in our Maryland nursing home lawyer blog.

The lawsuit claims that Henry Peters Dyck entered the hospital in July of 2008 with a condition on his right knee called hemarthrosis, that caused pain and bleeding in the joint of his right knee. Dyck was reportedly prescribed 10 – 30 mg of morphine in a liquid form every four hours as needed.

According to the lawsuit, filed by Dyck’s family, one week later, a nurse accidentally gave Dyck a cup of liquid morphine that contained 100 mg, instead of the 10 – 30 mg he was supposed to receive. The dosage was around five times stronger than his prescription called for, and this medication error caused Dyck to go into distress from the morphine poisoning.

The staff at the hospital reportedly tried to reverse the poisoning by pumping Dyck’s stomach, inducing vomiting and flushing his bowels, but the attempts failed, causing Dyck to suffer a heart attack. Dyck died four hours after the morphine overdose.

Dyck’s family claims in the lawsuit that the staff did not give him Naloxone, a drug known to be used as a remedy to stop the lift-threatening effects of morphine. The family alleges that the hospital’s attempts in saving Dyck’s life were not effective, caused him great pain and were physically invasive—all contributing in the end to Dyck’s wrongful death.

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According to a press release that our Baltimore pharmacy error attorneys have been following, Gold Standard/Elsevier, a drug information and medication management solution developer, has licensed MEDcounselor Drug Information modules to the Institute for Safe Medication Practices (ISMP) for its consumer website, ConsumerMedSafety.org.

The ISMP is certified by the federal government as a non-profit safety organization of physicians, pharmacists and nurses that strive to prevent medication error and adverse drug events. ISMP offers confidentiality and legal protection for patients who submit safety and medication error reports, and claims that Gold Standard’s MEDcounselor modules are a valuable tool to help consumers become more engaged with their health care, and to make more informed medication decisions—which could prevent medication errors, and patient injuries and deaths on a worldwide basis.

The MEDcounselor modules available through ConsumerMedSafety.org include:

• Drug Information: When typing in the first three letters of the name of a drug, patients and consumers have access to medication information like side effects, important usage, and drug interactions for every prescribed prescription drug in the United States. Over-the-counter (OTC) drugs, vitamins, and nutritional supplements are also included in this information.
• MEDcounselor is written to comply with all national standards for Consumer Medication Information (CMI) and is available in both Spanish and English languages to avoid medication error.
• Drug IDentifier: If capsules or tablets become separated from the original package or container, consumers will be able to identify the drugs quickly by entering the imprint or marking that usually appears in the form of numbers. Patients can also select from thirty colors and twenty-five drug tablet/capsule shape choices for identification.
• Drug Interactions: Consumers and patients will be able to access possible drug interactions between prescription drugs, OTC medication, herbal and nutritional supplements, as well as any food intake, caffeine, alcohol and tobacco products that may interfere with the drug. Drug interaction alert include severity ranking that is color-coded for ease of use, and increases the clarity for the user.

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As our attorneys from Lebowitz and Mzhen Personal Injury Lawyers discussed in a recent blog, although e-prescribing usage has increased in recent years, many local doctors claim that the current e-prescribing systems, although helpful for reducing medication errors, can lead to more mistakes in prescribing.

According to Todd Rowland, M.D. and director of medical informatics for Bloomington, Hospital in Indiana, although the majority of electronic health records systems offer electronic prescribing as an option, some still charge a fee to doctors who use the electronic transmissions for prescriptions. In some instances physicians can send the prescriptions by fax for free, but then get charged to send prescriptions electronically. He also said that physicians are on tight time schedules, and systems that are new require additional steps, that are often overlooked.

Rowland also claimed that right now, many e-prescribing systems have unnecessary drug interaction alerts that pop up while a doctor is prescribing. He claims that as doctors have time-sensitive practices, the e-prescribing should provide high quality information, that prevents medication error, but also fits into their practice, without slowing them down.

Last year, the Center for Medicare and Medicaid Services (CMS) promoted the switch to electronic prescribing by paying doctors a bonus for e-prescribing. By 2012, doctors who are not e-prescribing with be financially penalized by the federal government. As we reported in a recent blog, President Obama’s economic stimulus this year included over $19 billion for health information technology, to help doctors and hospitals pay for the cost of electronic medical records systems and to help improve the safety, quality and efficiency of healthcare.

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