October 16, 2014

British Columbia Woman Dies When Pharmacists Fail to Catch Dangerous Drug Combination

by Lebowitz & Mzhen

In a frightening case out of British Columbia, a 76-year-old, otherwise healthy woman died when she was prescribed two drugs that were known to have dangerous interactions. According to a report by one local news source, the error slipped past the physician, two pharmacists, and the computer system that tracks drug interactions.

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Evidently, the woman was on maintenance therapy for her colitis with a drug called mercaptopurine, an immunosuppressant. When the woman developed a case of gout, her prescribing doctor sent her to the pharmacy with a prescription for another drug. The two drugs were prescribed by the same doctor.

When she went to the pharmacy to fill her prescription for the new medication, no one at the pharmacy told her that the two drugs could be dangerous if taken together. The woman went home, continued taking her mercaptopurine, and started with the new drug as well.

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October 9, 2014

Pharmacist Overprescribes Blood-Thinner, Causing Man to Cough Up Blood

by Lebowitz & Mzhen

In a frightening case earlier last month out of New Zealand, a man needed to be hospitalized after he started to cough up blood due to a pharmacist's error. The pharmacist responsible was actually hired from a temp agency that staffs short-term employees.
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According to one local news source, a 65-year-old man went to fill a prescription for warfarin, a blood-thinner and anti-coagulant used to treat blood clots. Instead of providing him the required dose of a single 1 mg pill, the pharmacist filled the prescription for five 1 mg pills.

The man took the medication as instructed and six weeks later was complaining of extreme abdominal pain and constipation. He was hospitalized when he started coughing up blood and urinating blood. The man was taken off warfarin and placed on vitamin K instead. After five days in the hospital, doctors felt that he was okay to return back home. There is no indication as to what, if any, long-term effects the man may experience as a result of the overdose.

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October 2, 2014

Pharmacists Told To Keep Similarly Named Medications Away from Each Other

by Lebowitz & Mzhen

Pharmacists are charged with a very important duty in our society: to verify and fill prescriptions issued by physicians and to answer any patient questions that may arise. In addition, pharmacists are a second line of defense against physician error, checking prescriptions against other medications that the patient is taking.

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However, with the burden on pharmacists increasing as more and more people obtain healthcare, it seems that corners are being cut, potentially increasing the risk of a pharmacy error.

In fact, one report recently released by Pharmaceutical Journal discusses a recommendation that pharmacists keep similarly named medications physically apart from one another to reduce the chance of confusion.

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September 22, 2014

Michigan Woman Narrowly Avoids Serious Injury After Pharmacy Error

by Lebowitz & Mzhen

Earlier this month in Portage, Michigan, one local woman caught on to an error by her pharmacist that may have saved her life. According to a report by a local news source, the woman was provided a prescription by a local Wal-Mart pharmacy that belonged to another patient not once, but twice.

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Evidently, the woman takes an unknown medication daily and has her prescriptions filled at the local Wal-Mart pharmacy. However, last month she noticed that her daily pill looked a little larger than normal. She checked the label and saw that there was another patient’s name on it.

The woman did not disclose what medication she was supposed to be taking, but it is known that the prescription she was given was for a 78-year-old woman’s heart condition. There is no indication that the 78-year-old woman was provided any medication other than what she was prescribed. It’s possible she had not yet picked up her prescription.

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September 15, 2014

New Study Finds that Two-Thirds of Pharmacists Miss at Least 20% of Dispensing Errors

by Lebowitz & Mzhen

According to a study that was recently conducted in the United Kingdom, pharmacists miss errors in prescriptions in a frightening number of cases. According to a report by the Pharmaceutical Journal, the study results were unveiled at the Royal Pharmaceutical Society Annual Conference earlier this month.

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The study took 103 local pharmacists and had them fill 50 prescriptions in 25 minutes, which is generally considered a normal, if slightly heavy, workload for that amount of time. Five of the 50 prescriptions intentionally contained errors. There were also a few distractions that were thrown at the pharmacists while they were filling the test prescriptions, but nothing out of the ordinary for the profession.

The idea of the study was to see how many of the pharmacists would catch all five of the errors. The results were frightening. Below is a summary of the results:

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September 8, 2014

Woman Dies After Pharmacist Supplied the Wrong Surgical Dye

by Lebowitz & Mzhen

Not too long ago, two sons lost their mother during what was supposed to be a routine two-hour surgery to help deliver soothing medication to her aching muscles and bones. According to a report by the Boston Globe, the woman fell last summer and broke several of her vertebrae. Doctors fused several of the bones together to prevent them from moving, but her persistent pain continued.

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Eventually, doctors recommended a routine surgery to put a small pump under her skin to more quickly deliver medication to her spine and the surrounding muscles. As a part of the surgery, the surgeon needed to use a certain type of dye that is to be injected into the spine. However, when he asked the hospital’s pharmacist for the dye, the pharmacist replied that they didn’t carry that dye and provided an alternative.

Not looking at what the dye was, and assuming it was a replacement for the requested dye, the doctor injected the dye into the woman’s spine. After the surgery, the doctor told the woman’s sons that the surgery didn’t go as well as expected, but that the pump should still work.

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September 3, 2014

New Zealand Man Dies Due to Pharmacist’s Error

by Lebowitz & Mzhen

Earlier this month in New Zealand, a man died from a preventable and accidental overdose of rheumatoid arthritis medication, a doctor's error that went undetected by the pharmacist who filled the prescription. According to a report by a local New Zealand news source, the man had been diagnosed with rheumatoid arthritis for 20 years and had been on this exact medication previously. However, he had to be taken off the medication when his liver function started to decrease. Since then, he had been re-prescribed the medication after his liver function returned to normal.

medicaments-2-234571-m.jpg Evidently, the prescribing doctor made the first mistake, prescribing the medication to be taken daily rather than weekly as it should have been prescribed. When the man took the prescription to his local pharmacy, the pharmacist transcribed the prescription exactly as the doctor wrote it, instructing the man to take the medication daily.

Shortly after he began taking the medication, he noticed severe adverse side effects, such as mouth ulcers, a sore throat, and an abnormal blood count. When he went to have his symptoms checked out, he was diagnosed with methotrexate toxicity, a result of an overdose of the rheumatoid arthritis medication.

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August 28, 2014

Pharmacy Errors on the Rise Nationwide, Take Every Precaution Possible

by Lebowitz & Mzhen

From coast to coast, pharmacy errors have been on the rise lately. While some pharmacy errors are harmless, and many are caught before the patient actually ingests the medication, others can result in serious injury or death.

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One recent article from a local news source in Oklahoma City discusses the woes they are having in that area of the country with pharmacy errors. The writer of the article actually had a pharmacy provide her with the wrong drug the week she was writing the piece. Luckily, she caught the error before she took the medication, and the pharmacist provided her with an immediate apology and the correct medication.

However, not every time will a patient be so lucky to catch a pharmacist's error, nor is it a patient's responsibility to do so. Each year, there are thousands of injuries and deaths caused by medication errors. Many of these medication errors occur at local pharmacies across the country.

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August 20, 2014

Confusing Drug Names May Lead to More Prescription Drug Errors

by Lebowitz & Mzhen

Prescription drug injuries are becoming more and more common as pharmacies try to meet the increasing demands of their customers without hiring additional staff members. While there are several potential causes for a pharmacy misfill, one recent article points out that the similarity of different drug names may play a role in the confusion, increasing the chances of an error.

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Confusion Can Lead to Serious Injury or Even Death

Although some medication errors can cause little or no harm to the patient taking the drug, others can cause permanent or serious injury or even death. Suppose that the prescription is for a life-threatening condition that, if the patient does not get his or her medication, he or she could die. If a pharmacist fills that patient’s prescription with the wrong drug—even if the improperly prescribed drug was harmless—the patient may suffer serious injury or death.

Dosage confusion is also an area that can result in serious injury. If a doctor improperly prescribes a larger-than-needed dose, and the patient takes the prescribed dose, he or she may be at risk of an overdose. The same is true for an under-dose.

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August 13, 2014

Some Pharmacists Resist the Common-Sense Idea of Translating Prescription Instructions

by Lebowitz & Mzhen

In areas of the country where there is a large minority of non-English speakers, some pharmacies have been pressured to translate the prescription instructions into the predominant language in the area. For example, one article explains that some California pharmacies are being pressured to translate their instructions into Chinese and Vietnamese in order to cater to the large Chinese and Vietnamese communities in that state.
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Indeed, this makes intuitive sense. How can someone who does not speak English effectively translate and understand a prescription label? By translating the instructions for the patients, pharmacists help ensure that the patients are taking the medication as prescribed by the doctor. If patients don’t obey the prescriber’s instructions, there could be drastic consequences, such as serious injury or even death.

Pharmacists Resist the Idea

New York has recently passed a law that requires pharmacists to provide translated labels, and there is currently the same discussion going on in California as well. However, some pharmacists are resisting the idea. Those against the idea offer up two reasons. First, they claim that the translated labels would require larger bottles, and people generally prefer smaller bottles of medication. The risk is that if the bottle is too large, they argue, the patient is going to take the pills out of the bottle and put them into something more convenient, without the instructions.

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August 6, 2014

Some Hospitals Stepping Up Efforts to Curb Pharmaceutical Errors

by Lebowitz & Mzhen

Pharmacy errors are a serious problem in the American healthcare system. With nearly four billion prescriptions nationwide, and only 240,000 pharmacists, the ratio is not a favorable one for the patient looking to get his or her prescription filled. In fact, by some estimates, there are 2.2 to 3.7 million medication-dispensing errors each year. This equates to over 7,000 deaths each year across the country.

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Some hospitals are stepping up efforts to help reduce the number of pharmacy errors that occur in their facilities. According to a report by News-Press.com, Lee Memorial Health System in southern Florida has implemented a number of procedures that help with the rising rates of pharmacy errors. Below are a few of the steps the hospital has taken:

  • Computerized Prescriber Order Entry and Electronic Records ensure that the prescription that the doctor wants to provide to his or her patient is the one that is submitted to the pharmacist.
  • Bedside Barcode Medication Administration assigns each patient a barcode with all their medical information accessible to nurses and doctors who can scan the code. This helps decrease the chances of a medication mix-up.
  • Smart Infusion IV Pumps alert medical staff to any improper or excessive dose when they attempt to administer such a dose.
  • Integrated Care puts pharmacists on the front line with ER doctors to help make the medicine decisions.

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July 30, 2014

Parents Have a Hard Time When Dosing Children’s Medication Because of Metric-System Conversion

by Lebowitz & Mzhen

The United States is one of only three countries in the world that does not use the metric system in practice. While the official system of measurement in the States is the metric system, in reality, no one really uses it. However, this can cause a problem when children are given medication by their parents that requires knowledge of the metric system.

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In a recent study by Pediatrics, it is shown that about 40% of parents make a mistake—whether it be over- or under-dosing—when converting from the metric system to the American Standard System. The article proposes switching the United States over to the metric system, which would require a complete overhaul.

The article notes that most pharmacies use the standard system when providing dosing instructions. However, the pharmacists themselves use the metric system to dose the medication. This creates the necessity of a “margin of error” that all pharmacists must tolerate. However, such a margin of error can lead to over-dosing, under-dosing, and medication poisoning.

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