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.

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.

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.

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.

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.
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.

Some hospitals are stepping up efforts to help reduce the number of pharmacy errors that occur in their facilities. According to a report by, 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.

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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July 23, 2014

New Indian App May Decrease Prescription Errors By Increasing Legibility and Decreasing Translation Errors

by Lebowitz & Mzhen

It seems that there really is an app for everything. In a recent article by DNA India, a new app is on the market targeted towards Indian physicians. The app, called Safe RX, is a way for doctors to put in prescriptions for patients that ensure the prescriptions are legible. In addition, the app automatically can translate the prescription into 14 different languages, further decreasing any chance of confusion.

With the incidents of prescription error at an all-time high, apps like this one aim to fill a gap where oversight is minimal.

In addition to the safety aspects of the app, it will also automatically recommend generic equivalent for brand name prescriptions. This should help to keep medical costs down for people without insurance.

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July 16, 2014

Prescription Error Causes Man to Permanently Lose His Sight

by Lebowitz & Mzhen

Earlier this year in June, a Texas man filed a lawsuit against a CVS Pharmacy alleging that the pharmacy’s error caused him to permanently lose sight in one of his eyes. According to a report by a local news source, the man was given a prescription for eye drops to treat his pink eye back in 2012. When the man took the prescription to his local CVS Pharmacy, the prescription was filled with an ear medication with a similar name.

When the man took the medication home and put it in his eye, as the label on the box instructed, his eye became painful and irritated. Eventually, he completely lost sight in that eye. The box containing the drops clearly labeled the drug as ear medication. However, the pharmacist's label instructed the man to apply three drops of the medication in each eye twice daily.

The man’s caregiver told reporters that the loss of his sight has caused the man’s overall condition to deteriorate rapidly, requiring that he have nearly constant supervision. Texas state law limits the man’s potential recovery amount to $250,000.

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July 9, 2014

Baby Given Adult-Strength Painkillers in Pharmacy Error

by Lebowitz & Mzhen

In a frightening story out of North Houston earlier this month, an eight month old child was given painkillers instead of cold medicine by a local pharmacy. According to a report by a local news source, the child’s parents took her to the doctor complaining of a persistent cough and cold. The prescribing doctor called in a prescription to a local Walgreen’s pharmacy for the infant’s condition.

Upon picking up the prescription from Walgreen’s and giving it to her daughter, the woman’s mother noticed that the infant fell asleep immediately, one time with her eyes rolling back into her head. It wasn’t until about a week later that there was a knock on the door by a Walgreen’s pharmacy technician explaining to the mother that they had accidentally provided her daughter with adult-strength codeine instead of the cold medication prescribed by the girl’s doctor.

Walgreen’s acknowledged the mistake, taking ownership immediately. In fact, the company issued the following statement regarding the error:

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June 25, 2014

Hospitals Beginning to Place Pharmacists in the Emergency Room to Cut Down on Medication Errors

by Lebowitz & Mzhen

At the Children’s Medical Center in Dallas, Texas, 10 full-time pharmacists have been brought on to the staff to help combat medication errors in the emergency room. According to a recent report by NPR, the hospital views the addition of the pharmacists as a vital safety net.

perscription-drug-case-1156714-m.jpgAs one emergency room physician put it, “Every single order I put in is reviewed in real time by a pharmacist in the emergency department prior to dispensing and administering the medication." This is especially necessary in the emergency room, where there is no time to clarify what a doctor meant to prescribe.

The article also notes that medication errors are not necessarily caused by prescribing the wrong drug, although that is a large part of the problem. There are also thousands of cases each year where a patient is given a medication that they are allergic to or that reacts dangerously with another medication they are taking. Due in part to these reasons, medication errors are three times more likely to occur in children than in adults. In fact, one study found that nearly 25% of children’s prescriptions contain at least one error.

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