OMSS is a technology that was created to capture a digital image of a handwritten or printed prescription order and send it to the pharmacy—eliminating faxing, the use of a courier, or the use of pneumatic tubes to transport the information to the pharmacist. The idea behind OMSS was to accelerate the time the prescription hit the pharmacy, speed up the prescription filling process, with electronic filling, easy retrieval of scanned orders, and reduce the risk of transcription errors because the order can be magnified. Unfortunately, according to the article, these OMSS benefits are null and void if the pharmacy never receives the prescription orders.
The problem that is reportedly occurring is that multiple pages of orders are being pulled through the scanner at the same time, and the scanner is only reading a single page at a time—a problem that has also plagued pharmacies with faxing or copying orders in the past. When this problem occurs, staff may not be aware that only one page was scanned, and the pharmacist may not be aware that they should have received multiple pages of orders. As a result, drug omissions can take place, leading to medication mistakes or missed drug therapy.
In one documented case, a physician wrote three pages of admission orders for a patient suffering from lung cancer, as well as difficile colitis and fever. When the orders were scanned with OMSS, the pharmacy only received two pages of the orders, because one page was not pulled through. Neither the nurse who administered the medication the physician, nor the pharmacist noticed the prescription error and omission. The drugs prescribed on the missing page were seizure medications. By the forth day of receiving only a fraction of the medication, the patient was exhibiting behavior that lead the emergency response team to determine that the patient was having a seizure. The patient was transferred to critical care unit, where the doctor figured out the pharmacy mistake, and although the patient required intubation, he ultimately experienced a full recovery.
]]> The ISMP Safe Practice recommendations to prevent OMSS error are to:• Pull multiple pages through the scanner one page at a time
• Prepare the pages before scanning and remove all staples or folded sections.
• Number the pages so a nursing staff, or pharmacist will know the number of pages to expect.
• Monitor the receipt of the pages, to confirm that all pages were sent
• Check patient charts, and patient’s medical administration record entries (MAR).
• Review patient charts and drug therapy before changing the doctor or nurse shifts
• Encourage patients to be vocal about their medication needs, especially if they are not receiving a medication that they have been taking, or that they have been told they would receive.
• Clean the scanners to ensure clarity and performance
If you or someone you know has been injured by a medication mistake in Maryland or the Washington, D.C. area, contact the attorneys at Lebowitz and Mzhen, LLC for a free consultation. Call us today at 1-800-654-1949.
Order Scanning Systems May Pull Multiple Pages Through the Scanner at the Same Time, Leading to Drug Omissions, Institute for Safe Medication Practices, November 2009
Related Web Resources:
U.S. Food and Drug Administration: Medication Errors
Institute for Safe Medication Practices, (ISMP)
Institute of Medicine, (IOM)
National Coordinating Council for Medication Error Reporting and Prevention, (NCCMERP)
]]>According to ABC News, Maryland, Maine, Minnesota, Colorado, and Washington have all proposed new legislation that is trying to address the issue of dealing with excess and expired prescription medicine from nursing homes that end up in landfills and water sources every year, or if accidentally accessed by residents or other people, can cause serious harm or personal injury.
The Associated Press did a study in 2009, and reported that at least 250 million pounds of pharmaceuticals and contaminated medication packaging are generated in medical facilities every year. Some states are working on bills that would give nursing homes a choice to donate unused medication to charities in other countries. Other states are trying to send the unused medication back to the prescription drug manufacturers, with ‘take back’ programs, returning the responsibility back to the pharmaceutical company for disposal.
When a prescription is written for a resident in a nursing home, the pills aren’t reportedly dispensed in the same way that they are in a pharmacy. When the prescription is ordered for a nursing home resident, the pharmaceutical companies allegedly ship out 30-day supply cards, with each pill nestled in a small bubble pocket so nurses can easily pop the pill out of the card. If the patient has a bad reaction to the medication, if the patient passes away, or there is a medication mistake with the prescription, the medicine is most likely thrown out.
]]> According a nursing home in Colorado, nearly 50 percent of the medications sent to nursing homes from the pharmacy end up being disposed of. The home stated that the pharmaceutical companies do not frequently take the drugs back.The article states that since water treatment plants all over the country don’t have a filtration system in place to clear pharmaceutical waste out of water, environmental groups are encouraging people in their homes to throw the medicine in the trash, or asking hospitals to burn the medicine. The U.S. Food and Drug Association (FDA) recommends mixing unused medication with something undesirable like kitty litter or coffee grounds—anything to keep the drugs away from people, animals, or children and seal the medication from dissolving into the soil and groundwater.
In the meantime, local governments seem to be working hard to come up with a solution that works to keep nursing home residents and citizens healthy and safe from the disposal expired or excess medication.
Lebowitz and Mzhen, LLC represent victims of medication mistakes in Maryland or the Washington, D.C. area. Contact our attorneys today for a free consultation.
Where Should Unused Meds Go, ABC News, February 24, 2010
Related Web Resources:
]]>In the blog, our pharmacy error attorneys wrote about how President Barack Obama’s economic stimulus included over $19 billion for health information technology, and has given many hospitals great incentive to add their own funds and invest in adopting electronic records to improve the quality, safety, and efficiency of health and medical care.
One example of this comes from an article in the New England Journal of Medicine from last month, where the Long Island North Shore Hospital System in New York stated publicly that it will pay an up to $40,000 incentive offer to each doctor who agrees go electronic with health records—paying 50 percent of the total cost to doctors who install the Electronic Health Record that will communicate directly with the hospital, and will pay 85 percent of the total cost if the doctor shares quality care data.
The payment would reportedly add to the $44,000 physician incentive offer, where the American Recovery and Reinvestment Act of 2009 gave authority to Medicare to compensate health care professionals eligible for the payment, who used electronic health records in a meaningful way. According to the article, ‘meaningful use” is not yet clear in definition, but the overall aim is to transform the health care delivery system by using electronic records, to improve communication, efficiency, and quality care and reduce the risk of personal injury through medical mistakes or pharmacy error.
]]> Lebowitz and Mzhen, LLC represent victims of medication mistakes in Maryland or the Washington, D.C. area. Contact our attorneys today for a free consultation.Accelerating the Use of Electronic Health Records in Physician Practices, New England Journal of Medicine, January 21, 2010
Related Web Resources:
]]>Yesterday The New York Times published an article discussing the reported benefits of electronic records, and how President Obama’s economic stimulus that included $19.2 billion for health information technology, has given many hospitals incentive to invest in creating and using electronic records to improve the efficiency, quality, and safety of medical care. The goal according to the article is to integrate the various systems across the country with various hospitals and medical groups so medical records can be shared on a common platform within the different systems.
According to the article, the benefits of electronic health records are:
• If the doctor has immediate access to a patient’s record, it could reduce medical errors and personal injury within the hospital setting due to drug complications, pharmacy errors, drug allergies, or potential drug interactions, as well as drug recalls.
• Electronic records can eliminate duplicate tests, from M.R.I.’s to blood tests. If a patient is seeing multiple doctors, a new doctor can easily access their test results electronically within the same system, which can prove to be valuable in a life-threatening situation. If a test needs to be repeated, the doctor will have access to the results of the last test to compare.
]]> • Surgery can reportedly be made safer with access to electronic records. When a doctor has just finished multiple operations, there is a long list of health care steps that need to be performed with each patient, that include lab tests, blood clot checks, and nursing care instructions. When relying on a doctor's memory alone, important steps can be easily forgotten. With electronic reminders, each step must be done, and patient care is improved.• When a patient reportedly has electronic access to critical parts of their health records, like test results, they are able and often interested in improving their own health care, and can bring certain specific symptoms and health concerns to the attention to their doctors.
• By creating an electronic system, patients with chronic illnesses can be alerted with reminders and prompts when it is time for another office visit, or to regularly take prescribed medications. Electronic reminders also help patients receive better preventative care, like getting a flu shot, lab tests, or a colonoscopy. Electronic records can also help patients, doctors and pharmacists have a clear understanding of prescriptions and drug interactions, to avoid pharmacy error or misfill.
• When prescribing the right drug for a patient, electronic records can help the prescriber identify the right drug and dosage regimen. In the future, when variations in drug responses are identified according to DNA-based variations, doctors will be able to choose the best and most effective medication and dosage according to each patient’s unique genome.
The main concerns about electronic medical records revolve around privacy. The New York Times reports that the medical information will be password-protected, and that employers and insurers would only have access to a patient’s medical record if the patient gives authorization.
Medical Paper Trail Takes Electronic Turn, The New York Times, February 22, 2010
Related Web Resources:
]]>According the news story, after picking up her prescription acne medication at the Walmart pharmacy, she didn't realize that was mistakenly given Viagra capsules because the capsules were reportedly very similar to the medication she took in both shape, color, and size. She proceeded to take the Viagra without realizing the mistake, and claims to have suffered with health related conditions. It wasn’t until her family discovered the other patient label on the bottom of the bottle underneath her name that clearly indicated that the medication was Viagra, and intended for another patient.
The family of the teenager confronted the pharmacy at Walmart, and claimed that the college student has suffered many physical problems as a result of the pharmacy misfill and medication mistake. She claimed that after taking Viagra, she experienced serious health complications, including a racing heartbeat, extreme bodily temperature changes, anxiety and bouts of dizziness.
According to the U.S. Food and Drug Administration (FDA), 1.3 million people are injured every year in this country from medication errors, with at least one death reported every day. The National Coordinating Council for Medication Error Reporting and Prevention, (NCCMERP), reports that injury from medication error is an huge problem and health risk for the public, and needs to receive far more public attention. Medication mistakes can happen anytime in the pharmacy process, from prescribing, distribution, dispensing, administering or monitoring—often times resulting in personal injury.
Walmart Pharmacy Improperly Fills Teenager’s Acne Prescription with Viagra, New Jersey Newsroom.com, February 15, 2010
Related Web Resources:
U.S. Food and Drug Administration: Medication Error Reports
Institute for Safe Medication Practices, (ISMP)
Institute of Medicine, (IOM)
National Coordinating Council for Medication Error Reporting and Prevention, (NCCMERP)
]]>In one hospital pharmacy error in Oakland, California, a 90-year old emergency room patient at Kaiser Foundation Hospital, received a variety of blood pressure and stomach ulcer medications that were meant for another patient. The emergency room staff did not double check the medication orders sent from the pharmacy, and the patient went into severe respiratory distress after receiving the potassium chloride by mistake.
A rapid response team was sent in and the patient was reportedly breathing four to six breaths per minute with a fluctuating blood pressure. The man was intubated and put on a ventilator for breathing. Further testing proved that the patient lost brain function from the medication error. A physician interviewed by the California Health investigators claimed that he could not rule out the possibility that the medication mistake caused a severe change in the patient’s health.
In another case, at California Hospital Medical Center in Los Angeles, a patient was incorrectly given the drug Methotrexate, or chemotherapy, as a treatment for ectopic pregnancy—even though the patient was not in fact pregnant. Over the following week, the patient reportedly developed immune suppression, renal function decline, severe leukopenia and neutropenia, and oral, skin and esophageal ulcerations due to the medication error. The investigators reported that using chemotherapeutic medication on a patient who was not pregnant subjected the patient to serious health complications, physical harm, and injury.
]]> According to the CDPH, each hospital was fined $50,000 for failing to implement http://www.marylandaccidentlawblog.com/mt-static/images/formatting-icons/field-smaller.gifpolicies and procedures for the safe administering of medicine. The money received from these penalties will be used on projects to discover how these violations happened, and how future medical errors can be prevented in hospitals, to keep patients from enduring personal injury, physical harm, or even wrongful death.At Lebowitz and Mzhen LLC, our lawyers are experienced in defending medication error victims and their loved ones in the Washington D.C. area or in the state of Maryland. Contact us today at 1-800-654-1949 to schedule your free consultation, and receive the personal injury compensation you deserve.
California Hospitals Fined for Alleged Immediate Jeopardy Mistakes, Health Leaders Media, January 28, 2010
Bay Area Medical Mistakes: The Facts, NBC.com, January 28, 2010
CDPH Issues 16 Administrative Penalties to 13 Hospitals, CDPH Press Release, January 27, 2010
Related Web Resources:
California Department of Public Health: (CDPH)
National Coordinating Council for Medication Error Reporting and Prevention, (NCCMERP)
]]>According to the lawsuit filed in 2008, Reva Tosh received a prescription for a pain medication on November 11, 2006. When Tosh dropped off the prescription to the Rite Aid pharmacy two days later, the pharmacist misfilled the order with the steroid dexamethasone—a steroid with severe side effects often prescribed during cancer treatments.
Rite Aid Pharmacy allegedly gave Tosh more than seven times the regular dosage of the steroids for a period of 28 days, and she claimed to have developed a disorder of the adrenal glands called Cushing’s Syndrome, that caused her to suffer physical ailments, personal injury, and mental disorders, that confined her to a wheelchair.
During the trial, the the central issue was whether Tosh’s injuries were caused by the pharmacy misfill, or due to her preexisting illness of rheumatoid arthritis.
Reva Tosh was awarded $2 million in damages by the jury, and her husband Gerald Tosh received $500,000 for the his loss of her companionship.
]]> Rite Aid allegedly stated that it would not attempt to appeal the verdict, but that the damages awarded to Tosh were too high for the suffering that she endured. After the pharmacy error accident, Rite Aid retrained the entire staff at the pharmacy.At Lebowitz and Mzhen LLC, our attorneys are committed to making sure that pharmacy misfill victims and their loved ones receive the personal injury compensation they deserve in the Washington D.C. area, and in Maryland. Contact us today for a free consultation.
Rite Aid to Pay $2.5 M for Drug Mix-up, Montgomery Advertiser, January 27, 2010
Related Web Resources:
Institute for Safe Medication Practices, (ISMP)
Institute of Medicine, (IOM)
]]>Mable Mosley was taken to the Brandon Regional Hospital last year complaining of neck and shoulder pain. She checked into the hospital on a Saturday, and within a few days stopped breathing. Mosley was put on life support, and died days later.
Mosley’s husband is suing the hospital, the hospital owners, and seven individual pharmacists in the case, claming medication negligence and wrongful death—that his wife was given enough pain medicine to end her life.
The drug in question that Mosley received is called Duragesic, a patch containing large concentrations of opioid fentanyl, a potent narcotic approved in 1990 by the FDA for use in patients that have become opioid-tolerant from using another strong narcotic pain medication for a week or longer.
Opioids are chemicals that are commonly prescribed because of their pain relieving properties. Opioids work by attaching to opioid receptors, or proteins, found in the brain, spinal cord and gastrointestinal tract. When the drugs attach to the opioid receptors, they can block out the body’s perception of pain.
]]> Duragesic is only recommended to be used by “opioid-tolerant” people. In 2007, the U.S. Food and Drug Administration (FDA) warned against the use of fentanyl patches with patients who are not opioid-tolerant. According to the FDA warning, even the lowest strength fentanyl patch can cause severe side effects, and even death. Mable Mosley, according to the suit, was not opioid-tolerant.The lawsuit states that Mosley arrived in the ER with a high level of pain. The doctor who admitted her allegedly prescribed three pain medications, morphine sulfate, toradol and dilaudid, which significantly dropped her high level of pain. The suit alleges that later in the day, the same doctor then prescribed a 50-microgram Duragesic fentanyl patch.
The next day the doctor reportedly increased the Duragesic fentanyl patch dosage to 75 micrograms, and the following day to 100 micrograms. He then ordered additional medication called Neurotonin that treats nerve injury pain.
The suit alleges that all pharmacists should know that fentanyl patches are slow working pain relievers. Because of the skin patch, the delivery of the drug through the skin means that the highest levels of medication may not be reached for days. For Mosely, the second dose was applied less than 12 hours after the first. The manufacturer advises to wait 72 hours before increasing the pain medication dosage and the Duragesic leaflet warns that elderly patients should start with a patch that releases no more than 35 micrograms per hour. The suit claims that the hospital’s computerized “Narcotic Delivery System” didn’t catch the alleged medication mistake either.
According to the death summary, Mosley was described as obese and suffering from sleep apnea. The report did not mention fentanyl, rather stated that she became claustrophobic while getting an MRI, was nauseous and vomited before aspirating.
Our medication mistake attorneys at Lebowitz and Mzhen, LLC are committed to making sure that medication error victims and their loved ones receive the personal injury compensation they deserve. If you or someone you loved has been injured or died due to a pharmacy error in the Washington D.C. area or in the state of Maryland, contact us at 1-800-654-1949 to schedule your free consultation.
Widower Sues Over Wife’s Death at Brandon Hospital, St. Petersburg Times, December 30, 2009
Lawsuit Charges Hospital with Negligence, My Fox Tampa Bay, December 30, 3009
Related Web Resources:
National Institute on Drug Abuse: Research Report Series- Prescription Drugs: Abuse and Addiction
U.S. Food and Drug Administration: Second Safety Warming on Fentanyl Skin Patch
]]>The company has recalled these drugs based on consumer complaints of an unusual moldy, musty smell that reportedly caused nausea, vomiting, diarrhea and gastrointestinal pain. The smell was found to be caused by trace amounts of the chemical 2, 4, 6-tribromoanisole (TBA)—a chemical often applied to wood pallets that are used in the transportation and storage of the materials used for product packaging.
The FDA has criticized J&J for not reacting quickly enough to customer complaints, and for failing to fix the problem, a problem that has been familiar to J&J. Customers have reportedly been complaining since 2008 about their pills having a mildew-like odor. In December of 2009, Tylenol Arthritis Pain medication was also recalled related this same issue.
According to the FDA, J&J and McNeil did not conduct a quick and comprehensive investigation into the problem, and failed to provide high quality products to consumers—responsibly protecting them from personal injury or illness. Many consumer complaints were received as early as 2008 and 2009, and the test results indicating TBA contamination were not shared with the FDA until after an inspection.
]]> McNeill is continuing to investigate the issue and is reportedly taking further actions to discontinue the use of these wood pallets that contain TBA, to reduce the potential for consumer injury or illness from the products.The recalled OTC drugs are Regular and Extra Strength Tylenol, Tylenol PM, Children’s Tylenol, Simply Sleep, St. Joseph’s Aspirin, Extra Strength Rolaids, Motrin IB, Benadryl and Junior Strength Motrin. These products are widely sold through a number of large chain drug stores and pharmacies, supermarkets and independent pharmacies.
CNN reported that the FDA has issued a serious warning letter to Johnson & Johnson, saying the company has 15 days to address the problem and prevent future problems and violations—the failure of which could result in legal action, including seizure and injunction.
Lebowitz and Mzhen, LLC represent victims of medication mistakes in Maryland or the Washington, D.C. area. Contact our attorneys today for a free consultation.
McNeil Consumer Healthcare Announces Voluntary Recall of Certain Over-The-Counter (OTC) Products in the Americas, UAE, and Fiji, PRNewswire, January 15, 2010
Tylenol Recall: What’s That Smell?, The Wall Street Journal, January 15, 2010
J&J Widens Recall Amid FDA Pressure, Forbes, January 15, 2010
Tylenol Recall: FDA Slams Company, CNN Money, January 15, 2010
Related Web Resources:
According to the ISMP Error Alert article, nearly everyone in the healthcare industry uses shortcuts, like abbreviations and symbols, in an effort to save time when handwriting specifics for the prescription—including phrases, units of measure and words. Some shortcuts can in the end can be very time consuming, as they need to be checked and verified for accuracy on the receiving end. These verifications could also reportedly cause a greater chance for medication error than if the prescription was written out without abbreviations or symbols. The article claims that it is important to prevent future misunderstandings now, instead of waiting until medical abbreviations, dose designations or symbols lead to a patient injury.
The article lists a few common error-prone abbreviations, symbols and dosage misunderstandings that take more time for the pharmacist to check, and could cause medication mistakes:
• Some abbreviations that indicate the frequency of when to take the drug, can be difficult to understand, and can lead to error. In one prescription for “Penicillin VK 500 mg Q1D X 7D,” the physician accidentally typed “Q1D” (once a day) instead of “QID” (four times a day). The pharmacist realized the mistake, and that the patient was supposed to be taking the penicillin four times a day for seven days (7D). Another example of frequent error comes in the abbreviation for “D” (days), where it can also be mistaken for “doses.”
]]> • Many abbreviation mistakes come up in prescribing, with the use of “q.d.” (every day). When written in cursive, the loop of the "q" can cause the notation to read as “q.i.d.” (four times daily), or even “q.o.d.” (every other day). The article recommends writing out the directions “daily” and “every other day” instead of risking misinterpretations with abbreviations.• Another common pharmacy error can happen with the abbreviation “AD” (right ear). In one case, a pharmacist who was reportedly tired of writing out “as directed,” began to abbreviate that term as “AD.” The oral liquid prescription was then transcribed to read “one teaspoon three times daily in right ear.” When handwritten, a lowercase “a” can also easily be confused with an “o.” So a patient could be instructed to use medicine in the right eye, “OD” instead of the prescribed right ear, “AD.” The ISMP Error Alert Report recommends that the best practice is to always write out all directions for left and right eye and ear, to avoid medication error, or patient injury.
In a related blog, our lawyers discussed other ISMP Medication error cases, and what patients and the healthcare industry can do to prevent pharmacy misfill, or medication mistakes.
At Lebowitz and Mzhen, LLC, our attorneys are committed to representing victims of medical mistakes and their loved ones, in Maryland and the Washington D.C. area. Contact us today for a free consultation.
Shortcuts Don’t Save Time, ISMP Error Alert, November 2009
Related Web Resources:
Institute for Safe Medication Practices, (ISMP)
Council Recommendations: Promoting the Safe Use of Suffixes in Prescription Drug Names, National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP)
]]>According to reports, 21 of the 25 horses of the Venezuelan polo team were allegedly given an a drug mixed to replicate the name-brand supplement Biodyl—a concoction of vitamins and minerals often used to treat muscle fatigue in horses. Biodyl is reportedly used safely around the world, but hasn’t been approved by the U.S. Food and Drug Administration for this country.
The drug concoction was prepared by Franck’s Pharmacy Compounding Lab in Ocala, and the mixture allegedly contained a strength of an ingredient that was incorrect—making the horses sick and causing their tragic death at the International Polo Club of Palm Beach in Wellington, Florida. Only the horses treated with the medication mistake became sick and died within hours of treatment, after collapsing, as they were unloaded from their trailers where they were scheduled to play in the U.S. Polo Open.
Fox News reported that veterinarians commonly turn to compounding pharmacies for medications that aren’t readily available on pharmacy shelves. The Lechuza polo team said in a statement that a Florida-based veterinarian wrote a prescription for the pharmacy to create a compound similar to Biodyl, after using the manufactured version of the drug for many years without problems.
]]> According to the U.S. Food and Drug Administration, pharmacy compounding is defined as the process of producing a drug that has the necessary medication ingredients to meet an individual patient’s needs medically. Compounding labs specialize in producing medications that are not commercially available, as well as creating medications for patients who need different forms and dosages than they can find commercially. Any licensed pharmacist can compound drugs, but a doctor’s prescription is required.Patients who seek compounded drugs are often allergic to inactive ingredients in FDA-approved medicines. According to the FDA, compounded drugs are not reviewed by the FDA for safety or effectiveness. Franck’s is regulated by the Florida Department of Health, along with other compounding labs in the state—and is required to keep detailed records of each medication batch it produces.
The FDA had strong interest in this case, as these deaths were caused by a medical mistake at the pharmacy—the same pharmacy that produces drugs for humans. Drug compounding has been criticized for lack of oversight, and patients, either human or animal, can sometimes be given medication that has not been tested—resulting in the potential for personal injury or even in this case death.
It was not clear how closely the pharmacy’s mixture was to Biotyn—but the Lechuza polo team had hoped for a supplement that contained vitamin B, magnesium, potassium, and selenium, which can be deadly in high doses. After an investigation, pathologists and toxicologists reportedly found high levels of selenium in the horses. The pharmacy publicly admitted to the mistake, and said that after an internal investigation, they found that the strength of the ingredient in the medication was not correct for the horses.
If you or a loved one have been harmed by a medication mistake in Maryland or Washington, D.C., contact our experienced attorneys at Lebowitz and Mzhen, LLC for a free consultation. We are dedicated to making sure that victims and their families receive the personal injury compensation they deserve.
2009 Top News Countdown: No. 5: Local Pharmacy mistake Leaves 21 Polo Horses Dead, Ocala.com, December 26, 2009
Polo Horse Deaths Put Focus on Custom Made Meds, Ocala.com, April 30, 2009
Vet Grief-Stricken Over Death of 21 Polo Horses, NBC Sports, April 25, 2009
Pharmacy Admits Mistake in Polo Pony Meds, ABC News, April 23, 2009
Related Web Resources:
U.S. Food and Drug Administration: Medication Error Reports
National Coordinating Council for Medication Error Reporting and Prevention, (NCCMERP)
]]>The article revealed how the possible errors are made and also discussed what steps pharmacies are making to try and prevent these errors, and reduce the number of pharmacy mistakes and patient injuries that could happen in the future.
Pharmacies are trying to prevent errors by:
• Encouraging improved communications between doctors and pharmacies.
• Encouraging doctors to write the prescriptions in full length, instead of using medical codes or abbreviations.
• Trying to transition from prescriptions that are handwritten to electronic prescribing—where a doctor sends the prescription directly from the doctors’ offices to the pharmacy computers.
• Computers are being used to aid the prescribing process, with more alerts for drug interactions, allergies, or patient’s illnesses.
• Other computer safety features include popup boxes when a technician enters or confuses a drug name with similarly named drug. After the popup appears, the technician has to initial the box to show he checked the drug.
]]> • A hardcopy of the prescription is scanned into the computer system so the pharmacist can verify the prescription on a split screen—to review the pharmacy filled with the original prescription.• Computer screens show a color picture of the bottle and the prescribed drug, as well as the shape and marking on the pills or capsules inside.
• Pharmacies are being encouraged to separate drugs with similar names on the drug supply shelves.
• Warning signs have been placed in drug supply areas to remind pharmacy staff to always double-check medications with names that are similar.
• The most dangerous drugs like narcotic painkillers are kept locked away in a cabinet or safe that only the pharmacist has access to.
• Pharmacists are encouraged to open the bottle in front of the patient to inspect the contents, as well as the inspection of the shape, color or markings on the pills or capsules.
• The Pharmacist can also prevent medication error by discussing with the patient what the drug was prescribed for, what condition is and how to take the medication.
At Lebowitz and Mzhen, our lawyers are committed to making sure that pharmacy misfill victims and their loved ones receive the personal injury compensation they deserve. If you or someone you loved has been injured due to a pharmacy error in the Washington D.C. area or in the state of Maryland, contact us today for a free consultation.
Prescription Errors: A Prescription’s Path Through a Pharmacy, USA Today
Related Web Resources:
U.S. Food and Drug Administration: Medication Error Reports
National Coordinating Council for Medication Error Reporting and Prevention, (NCCMERP)
]]>In the research, USA Today interviewed pharmacy experts and toured two pharmacies, a CVS and Walgreens, to study the six steps of the prescription filling process, and the potential errors that can happen along the way, as well as real cases that have caused actual injuries or death.
Step 1: Prescription received
When the customer drops off the prescription to the technician, or the doctor’s office calls in the prescription, errors can occur if a technician misunderstands a doctor's handwriting, prescription codes and abbreviations or misunderstands the oral instructions over the phone. In one case, a doctor’s prescription for methadone read “sig 4 tablet BID for chronic pain,” which means “Please label (sig) this drug to say: take 4 tablets twice per day (BID) for chronic pain. The technician typed, “Take 4 tables by mouth as needed for chronic pain.” The patient allegedly died of an overdose of methadone.
Step 2: Prescription entry
A technician then scans the original prescription into the computer and manually enters the patient’s personal data, like name, address, date of birth and phone number, as well as drug information, strength, dosage instructions and quantity. If a technician incorrectly types the prescribed drug dosage, formulation or the patient’s medical condition, history or allergies into the computer, then serious errors can occur, including personal injury. Also if the wrong drug code is chosen in the computer system, it can be mistaken for a similarly named drug. In one instance, a pharmacy was asked to fill a prescription for compazine, an anti-nausea drug, (COM) and accidentally gave the patient a generic substitute for coumadin, a blood thinner (COU).
Step 4: Filling the prescriptions
A technician then takes medication from the drug storage shelves and matches the Identification number with the prescribed drug. The technician also scans the bar code on the bottle and the information sheet to make sure they are an exact match. A label is printed out, and the technician counts out the pills, fills the vials and puts the prescription into baskets that are coded by color—for immediate patient pick up or later. Pharmacy error can often happen if the technician selects the wrong drug, or the right drug with the wrong strength—as the drugs are often stored near drugs with similar names and can be confused with other drugs that are similarly named. In one case, a child’s prescription for Zyrtec, an antihistamine, was misfiled with Zantac, a drug to control stomach acid.
Step 5: Final verification
The pharmacist checks the patient’s name, number of the prescription, and all other information in the computer against the original prescription, as well as taking a scan of the bar code on the bottle and comparing the photo of the pill in the computer with the actual medication. The pharmacist also double checks for any potential allergies or drug interactions with other medications. Errors are made in this final verification if the pharmacist doesn’t find the error made between the prescribed drug and the medication chosen, or if the pharmacist neglects to check the bottle’s contents.
Step 6: Completing the sale
The cashier on duty, often an entry-level technician, rings up the sale and then asks if the patient would like to talk to the pharmacist about the drug’s purpose, instructions, and possible side effects. Errors are possible here when the pharmacist doesn’t automatically provide medication counseling when the prescriptions are picked up.
In a related blog, our pharmacy misfill attorneys discussed the importance of getting to know your pharmacists—and how the discussion of your current drugs, dosages, and interactions can help prevent pharmacy misfills, mistakes, and possibly prevent personal injury.
If you or someone you know has been injured by a pharmacy mistake or misfill in Maryland or the Washington, D.C. area, contact the attorneys at Lebowitz and Mzhen, LLC for a free consultation.
Prescription Errors: A Prescription’s Path Through a Pharmacy, USA Today
Related Web Resources:
American Pharmacists Association: APhM, American Pharmacists Month 2009
]]>According to the suit, Sheridan was prescribed Temodar, a powerful drug for brain tumors that was part of his treatment of cancer in September 2007. The prescription was allegedly written incorrectly, and Sheridan was wrongly prescribed 10 times the correct dosage—he reportedly took the medicine daily when it was only to be used every other week. Rite Aid Pharmacy allegedly dispensed the drug to Sheridan, without checking with Sheridan’s oncologist for a second opinion to clarify the prescription mistake.
The lawsuit accuses a Rite Aid pharmacy for contributing in the wrongful death of Sheridan, who reportedly had consumed toxic doses of the cancer medication. According to the Associated Press, the doctor who wrote the incorrect prescription has settled with Sheridan’s estate.
According to a 2006 report from the Institute of Medicine, at least 1.5 million Americans are injured by medication mistakes every year, and nearly 7,000 people die every year from medication errors annually.
]]> Our attorneys at Lebowitz and Mzhen, LLC are committed to making sure that victims of medication error and their loved ones receive the personal injury or wrongful death compensation they deserve. If someone you know has been injured or has died due to a pharmacy error in the Washington D.C. area or in the state of Maryland, contact us at 1-800-654-1949 to schedule your free consultation.Rite Aid Blamed in Mich. Man’s Death, CBS News/AP, December 22, 2009
Pharmacy Faces Lawsuit, Detroit Free Press, December 22, 2009
IOM Q&A: Medication Errors in the United States, Johns Hopkins Bloomberg School of Public Health, August 3, 2006
Related Web Resources:
Institute for Safe Medication Practices, (ISMP)
Institute of Medicine, (IOM)
The recall dosages are single-dose pre-filled syringes containing the vaccine specifically created for children ages 6 to 35 months. It is a voluntary, nationwide recall by Sanofi Pasteur.
During testing at the time of the vaccine’s manufacture, the doses contained 7.5 micrograms of antigen, the recommended dosage used to stimulate immunity in children. But later testing showed degradation of the vaccine, making it less potent than desired. This proved to be the case with four lots of the vaccine, totaling 800,000 doses.
According to the Centers for Disease Control Prevention (CDC), this recall is part of a routine quality assurance program and is non-safety related. Children who received the vaccine do not need to be re-immunized, but with future immunizations, children should be given the proper vaccination dosage. With children who have only received one vaccine dose, they should get the get their scheduled second dose.
]]> David Paulson, Maryland Health Department spokesman, stated that Maryland has received 10,300 doses from the affected vaccine lots—going to 48 providers, though not to any local health departments. Although this recall is non-safety related, health officials in Maryland and Virginia are notifying healthcare providers and other vaccinators of the vaccine recall as well as the specific CDC guidance, to avoid any potential for vaccination error, or patient injury.At Lebowitz and Mzhen LLC, our attorneys are committed to representing victims of medical mistakes and their loved ones, in Maryland and the Washington D.C. area. Contact us today for a free consultation.
Doses of Swine Flu Vaccine for Young Children are Recalled in Md., Va., The Washington Post, December 15, 2009
800,000 Doses of Swine Flu Vaccine Recalled, The Los Angeles Times, December 16, 2009
Related Web Resources:
CDC: Related Voluntary Recall of Certain Lots of Sanofi Pasteur H1N1 Pediatric Vaccine in Pre-Filled Syringes Questions & Answers, December 15, 2009