Pharmacy Error Injury Lawyer Blog

A recent article from the Institute for Safe Medication Practices (ISMP) that our Maryland-based medication error attorneys have been reading reported that the order management scanning system (OMSS) technology that was created to improve the efficiency and safety of the drug ordering process for doctors and pharmacies, is now experiencing error-prone problems that are leading to medication errors, drug omissions and missed drug therapy in patients.

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.

Continue reading "ISMP Reports of New Medication Errors Leading to Drug Omissions" »

As Maryland Pharmacy Error Attorneys, we have been following a recent report by The Institute for Safe Medication Practices (ISMP) about the danger of error-prone abbreviations and when it comes to writing a prescription—the fact that some shortcuts don’t save time, and can result in pharmacy error or injury.

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.”

Continue reading "Dangerous Error-Prone Prescription Abbreviations" »

In a recent study that our Maryland Pharmacy Error Attorneys have been following, USA Today investigated every step of a prescription’s path in a pharmacy—to uncover the potential for medication mistakes with each step of the filling process, that can lead to patient injury or wrongful death.

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).

Continue reading "Understanding the Prescription Drug’s Path through a Pharmacy can Reduce Error" »

Our Maryland Pharmacy Error Injury Lawyers have been following the recent case filed last week on behalf of John Sheridan, a man who died after being prescribed the wrong dosage of a cancer medication.

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.

Continue reading "Pharmacy Mistake Leads to Wrongful Death—Rite Aid Faces Lawsuit" »

As Maryland Medication Mistake Attorneys we have recently read an article published in the QJM, the long-established leading general medical journal, on the topic of medication errors—giving an overview of what medication mistakes are, how they happen, and how to prevent them from happening in the future.

According to the article, published in August 2009, a medication error is a failure in the process of treatment that can lead to the harming or personal injury of a patient. Medication errors can often occur in:

• Prescribing faults: ineffective prescribing, irrational or inappropriate prescribing, under-prescribing and over-prescribing when deciding which treatment and dosage plan to take.

• Prescription writing: illegibility

• Formulation manufacturing: incorrect strength, misleading packaging

• Drug formulation dispensing: incorrect drug, formulation and label

• Administering the medicine: incorrect dosage, wrong directions for frequency, invalid duration of treatment

• Monitoring drug therapy treatment and drug treatment alteration when required

Medication errors can be classified, according to the article, by the use of psychological error classifications—knowledge-errors, rule-errors, action-errors, and memory-based errors. It is important to detect the medication mistakes, that can range from trivial to serious, and to create a working environment that is free of blame, and encourages the reporting of errors.

The article also recommends, “balanced prescribing” to avoid medication errors. In balanced prescribing, the mechanism of action of the drug should complement the pathophysiology of the disease—optimizing the balance of benefit to harm.

Continue reading "QJM: How to Prevent Medication Errors and Injury with Balanced Prescribing" »

The FDA has recently published a patient safety alert, reporting medication dosage errors associated with Tamiflu, (for oral suspension), the top doctor prescribed anti-viral flu medication, administered to both adults and children. Our Maryland Pharmacy Misfill Injury Attorneys have been following this prescriber and pharmacy alert report, and how it could effect patient safety in this current H1N1 influenza pandemic.

According to the agency alert, the FDA has received reports that the Tamiflu (oral suspension) dosing instructions for the patient do not match the dosing dispenser. U.S. health providers often write liquid medicine prescriptions in teaspoons or milliliters (mL), while the dosage of Tamiflu is in milligrams (mg). Prescribers and pharmacists have been warned that Tamiflu's dosing dispenser included in the package has markings only in mg—30, 45, and 60.

The alert recommends that:

• If the dosing dispenser included with the drug is in mg, prescribers should write doses in mg

• Pharmacists should also ensure that the unit measurements on the instructions of the prescriptions match the dosage dispenser included.

• If the prescription instructions specify that the drug is administered using mL, the dosing device should be replaced with a new measuring device and calibrated in mL.

Tamiflu (oseltamivir) is an antiviral drug that slows the spreading of the influenza virus in the body. According to the Centers for Disease Control and Prevention (CDC), 22 million Americans have become ill with the H1N1 virus in the past six months, and 3,900 have died— 540 of which were pediatric deaths. The number of people who have been hospitalized is reportedly 98,000, with 36,000 patients younger than 17. The largest majority of deaths have been between the ages of 18 and 64—around 2,920.

Maryland’s Department of Health and Mental Hygiene reported last week that six more people have died in Maryland in the past four weeks from the swine flu, bringing the total death toll to 19 since the pandemic began. The H1N1 virus has also hospitalized 664 people in Maryland.

The Los Angeles Times reported that in the last week of October, 587,960 prescriptions for Tamiflu and other antiviral drugs were filled in the United States— according to Wolters Kluwer Pharma Solutions of Bridgewater, N.J., the company that tracks FDA prescription data.

If you or someone you know has been injured by a medication mistake or pharmacy misfill 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.

FDA Public Health Alert: Potential Medication Errors with Tamiflu for Oral Suspension

New CDC Estimates Show What Toll Swine Flu is Taking in U.S., Wasington Post, November 13, 2009

Booster Shots: Swine Flu Continues Slow Climb on College Campuses, The Los Angeles Times, November 13, 2009

Swine Flu Kills 6 More People in Maryland: All Had Underlying Conditions, Baltimore Sun, November 13, 2009

Related Web Resources:

U.S. Food and Drug Administration, (FDA)

In the ongoing topic of medical error and injuries that our Maryland Medication Mistake Lawyers covered earlier this week in a previous blog, the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) recommends that in order to help prevent medical error injury and death every year, it is important that the prescribers of medication avoid the use of dangerous abbreviations in prescriptions, including those for drug names and Latin directions for use.

The current NCCMERP list of dangerous abbreviations commonly made by prescibers include:

• Mistaking “µg” for “mg” or milligrams, resulting in an overdose

• “U” is mistaken for zero or a 4, which also results in an overdose. “U” is intended to mean “Units” but with poor handwriting, it can also be mistaken for “cc” or cubic centimeters.

• “Q.D.” means “every day” in Latin. The period after the “Q” is sometimes mistaken for an “I”—and the drug is given “QID” (four times daily), which results in an overdose.

• “T I W” means three times a week. This is often misinterpreted as “three times a day"

• “IU” means International Unit, and is often mistaken for “IV” or intravenous

• “AU, AS, AD” are the Latin abbreviations both ears, left ear and right ear. These are often misinterpreted as the Latin abbreviation “OU” (both eyes), “OS” (left eye), and “OD” (right eye)

The Council also recommends that in order to enhance the accuracy of prescription writing and communications, doctors, nursing and pharmacy staff should:

• Make sure all prescriptions are legible and include notes on medication purpose—like cough, or allergies—maintaining that the proper medication is dispensed.

• All prescription orders should be written in the metric system, except for orders that use standard units like vitamins or insulin. Units should also be written out, rather than abbreviated with “U”

• Medication orders should include the exact drug name, metric weight or concentration, dosage form, with strength and concentration expressed in metric amounts.

• The NCCMERP reports that numerous errors in drug strength and dosage have occurred with the use of decimals—due to the trailing zero (1.0 mg) or the lack of a leading zero (0.1 mg). A leading zero should always be used before a decimal, and trailing zeros should never be used.

Continue reading "Dangerous Drug Abbreviations that Lead to Medical Injury" »

As Maryland Medication Error Injury Attorneys, we have recently read data from the U.S. Food and Drug Administration (FDA) stating that in the United States, 1.3 million people are injured by medication errors every year, with at least one death reported every day.

According to the National Coordinating Council for Medication Error Reporting and Prevention, (NCCMERP), injury from medication error is an urgent, a widespread public problem, that needs to receive far more public attention. The NCCMERP estimates that 98,000 people die annually from medical errors that occur in hospitals—an amount that is greater than deaths from motor vehicle accidents, breast cancer, AIDS, even workplace injuries. Medication error can happen at any point, and result in injury—from communication, distribution, prescribing, dispensing, administering or monitoring.

A medication error is defined by the the NCCMERP as any event that is preventable, and may cause medication misusage or patient harm while the medication is being controlled by the health care professional, consumer or patient. Medication errors can happen in professional practices and during procedures, as well as in the systems of prescribing, ordering, the labeling of a product, packaging, dispensing, education, monitoring, usage, and naming conventions.

The FDA states that common causes of medication error stem from poor communication between doctor, pharmacist, and patient, with unclear product names or suffixes, medical abbreviations or handwriting, poor techniques or procedures, or a lack of understanding of directions for patient usage. Job stress or lack of training or knowledge can also lead or contribute to pharmacy error injury or misfills.

Continue reading "Death from Medication Error Leads to Prevention Awareness" »

As Maryland Medication Mistake Attorneys, we have been following a recent article from Cardiology Today, revealing that cardiac medication mistakes are reported most commonly with infants—in community hospitals, university hospitals, and pharmacies.

The results of a study showed that diuretics and antihypertensive agents are the most commonly reported drugs that are improperly dosed with infants—frequently prescribed by doctors for pediatric patients with heart disease. According to the article, these drugs have the potential for more widespread use because of neonatal care advances, and the increasing incidence of metabolic syndrome and childhood obesity.

Diuretics and antihypertensive agents are considered by many to be safe, because of their frequent use by doctors, but according to the research, it would be much more beneficial for the physicians, clinicians and pharmacists to have accurate information on the assessments of harm rates, and the groups of infant patients who are at particular risk—to prevent serious medical mistake errors and injury with children.

The most harmful error reports came from reported dosing error of the heart condition drugs: nesiritide, calcium channel blockers, milrinone, digozin, and antiarrhythmic agents.

According to the results from voluntary CV medication error reports that were submitted to a medication error database from the years 2003 and 2004, 50% of the total errors reported occurred in children younger than 1 year of age, and 90% of the error reports occurred in infants younger than 6 months of age.

In the 1,424 causes reported, the most frequent causes of medication error or pharmacy misfills were:

• Human error
• Improper dosing
• Missed or double doses
• Misunderstanding of drug orders
• Mathematical errors which include dilutional errors

Continue reading "Cardiac Medication Dosing Errors Reported Most Commonly With Infants" »

In a prior post from this week concerning pharmacy error injury, our Maryland Medication Error Attorneys at Lebowitz & Mzhen, LLC discussed a recent study published by the Institute of Medication Practices (ISMP), and the ongoing problem with drug naming standards in extended release medications.

In this study, the ISMP revealed a series of cases reported to the institute, in which drug name suffix medication mistakes have frequently occurred. This study showed specific case examples in order to establish clearer naming conventions in the industry, and improve comprehensive pharmacist and patient awareness—to prevent pharmacy error injury and misfills in the future.

The ISMP study reported these specific medication mistake cases:

• Physicians often prescribe extended release products without the correct suffix, or with a suffix that does not exist for that particular product.

• In an analysis of 402 prescribing errors published by Medscape Pharmacists, the most common type of error in the study (280 cases, 69.7%) was failure to specify the controlled release formulation.

• The ISMP received reports of cases in which pharmacists dispensed Metadate ER instead of Metadate CD—two different extended release forms of methylphenidate-UCB, a stimulant medicine commonly used to treat ADHD. In one case, a prescription for Metadate CD 20 mg was misfiled at a pharmacy, where the staff dispensed Metadate ER 20 mg.

• Some products have multiple suffixes for different formulations of the same drug. Diltiazem products for example (calcium channel blockers) are used to slow the heart rate and normalize the heart rhythm in hypertension and arrhythmia. The many suffixes for Diltiazem include SR, CD, XR, XT, and LA.

• Electronic prescribing can also lead to medication errors on behalf of the prescriber. In one case, a prescriber electronically selected metroprolol tartrate instead of metoprolol succinate because of choosing incorrectly on his PDA.

According to this report, pharmacists, practitioners, and patients should take extra care when reviewing the different formulations and medication names, especially if the medication is available in more than one dosage form.

The ISMP recommends the following medication error prevention checklist:

Continue reading "ISMP Medication Error Cases and Prevention Checklist" »

As Maryland Medication Error Attorneys, we have been following a recent study published by the Institute of Safe Medication Practices (ISMP), about the lack of prescription drug naming standards in extended release medications that lead to pharmacy error injury.

According to the study, although extended release drug formulations provide multiple benefits for many patients, the titles used for many medications are often confusing, and can cause patient error when the same drug is presented with several different oral dosage forms in the suffix.

Extended release drug formulations play an important role in maintaining consistent prescription therapies, by preventing the need for patients to remember to repeat dosages—delivering a steady dose of the medication throughout a specific period of time. The difficulty with many of these medications comes in the name. According to the study, drug manufacturers add suffixes or modifiers to already well-known medication names, to keep awareness of the brand, yet differentiate between the immediate-release counterparts. For example: Wellbutrin SR is a sustained release anti-depressant, whereas Wellbutrin XL is the extended-release version. Same name, different release rate.

ISMP reported that there is currently no standardization for the many different types of extended release formulations, nor is there any standard definition describing the dosage or release characteristics of the drugs. Patients are left to discern between identical formulations with different suffixes, or even similar prescription suffixes with dissimilar formulations, creating potential for pharmacy error injury or misfills.

The ISMP has recommended to the United States Pharmacopeial Convention (USP) that naming standards be established to avoid patient confusion with the many similar formulations of the same drug, by incorporating suffixes or descriptive phrases into the drug names, or by inventing new brand names to designate different formulation properties. The FDA is also reportedly aware of the suffix problems and currently exploring new ideas to improve the naming convention.

If you or someone you know has experienced pharmacy error injury in Maryland or Washington, D.C., contact the attorneys at Lebowitz and Mzhen, LLC for a free consultation.

The Alphabet Soup of Drug Names Suffixes, ISMP Error Alert—Pharmacy Today, August 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)

MedWatch: The FDA Safety Information and Adverse Event Reporting Program

One of the sources of information that we read regularly is published by the Institute of Safe Medication Practices. Recently, the ISMP wrote about individuals who were using a dosage cap from one over the counter medication, to measure medication from another medication.

When the measuring cups were swapped as described above, the result was that the individual taking the medication received an overdose of medication. Just as a reminder, Maryland medication error attorneys at Lebowitz & Mzhen, LLC recommend that measuring cups stay with the produce that they are designed to measure so that easily avoidable, but potentially dangerous, errors are avoided.

Maryland pharmacy error attorneys serve a number of clients who do not speak English as their first language. Some of these clients have raised the issue of not being able to receive prescriptions or dosage instructions written or spoken in their native languages from big box pharmacies. The attorneys at Lebowitz & Mzhen, LLC believe that this shortcoming places a large number of citizens in danger of harmful pharmacy errors. According to the 2000 US Census, 667,357 Marylanders speak a language other than English in their homes.

As we discussed in an earlier post, Maryland pharmacists must provide medication counseling to patients when requested, and must provide written dosage instructions with prescriptions. Counseling and written instructions in English are useless to a pharmacy patient that has difficulty understanding the language.

Pharmacy Today reports that following an undercover investigation by New York Attorney General, Andrew Cuomo, Rite Aide and CVS have agreed to provide medication instructions in languages other than English at their New York locations. The investigation began after reports that pharmacies failed to provide side effect information and drug interaction warnings in patients’ native language. New York Rite Aid and CVS locations will now provide dosage and side effect information to patients in Russian, Spanish, Chinese, Italian, French and Polish. The companies also agreed to provide assistance using an over the phone translation service.

Our attorneys believe that Maryland pharmacies should follow suit and help ensure that all patients fully understand their medication dosage instructions and other relevant information.

Continue reading "New York Pharmacies to Provide Foreign Language Prescription Instructions" »

Recently, University of Massachusetts Medical School researchers concluded that medication errors are increasingly common at outpatient cancer clinics across the country. The report reviewed nearly 11,000 prescriptions dispensed at adult and pediatric oncology clinics nationwide. The research published in the Journal of Oncology, found medication errors in 18% of pediatric visits and 7% of adult visits.

The researchers also found that patients made dosage mistakes at home due to poor communication between doctors, pharmacists and the patients. The authors concluded that better communication between oncology clinics and pharmacists would prevent many prescription errors. One of the clinics reviewed in the study utilized an electronic record keeping system. Not surprisingly, the computerized system reduced the frequency of medication errors.

The medication error attorneys at Lebowitz & Mzhen, LLC suggest that our readers always check with their nurses and physicians prior to receiving any intravenous medication to make sure that the correct drug and dosage are being supplied.

Continue reading "Medication Errors Common in Hospital Outpatient Cancer Clinics" »