Pharmacy Error Injury Lawyer Blog

As our Baltimore, Maryland pharmacy error injury attorneys reported in a recent blog, pharmacy errors or misfills can happen in every step of a prescription’s path in a pharmacy. Many factors can lead to prescription error, including misunderstanding a doctor’s handwriting, making mistakes with prescription codes or abbreviations, and misreading a patient's medical conditions or medication list, among others.

In a recent pharmacy mistake lawsuit, filed last month, Charles Stevens, 70, was given a prescription for Lomotil, an anti-diarrhea medicine that he dropped off to be filled at his local CVS Pharmacy in Santa Barbara, CA in 2009. When Stevens picked up his prescription, he was allegedly mistakenly given a prescription for Warfarin Sodium, a medication prescribed for blood-thinning. Stevens was reportedly already taking blood-thinning medication, and after taking the prescription misfill, he suffered major bleeding, and was immediately taken by his wife to the hospital.

Stevens and his wife are reportedly suing CVS for pharmacy negligence, and pharmacy malpractice, claiming that the pharmacy failed to read the prescription correctly, misfilled his medication bottle with incorrect drugs, and failed to properly analyze Stevens’ medication profile, which could have prevented the medication mistake.

CVS reportedly has a patient profile mechanism that is used to protect patients from such dangerous drug errors as well as dangerous drug combinations, or repeat or double-diagnoses. According to Stevens' attorney, CVS reportedly admitted to the pharmacy mistake and Stevens’ lawyers are asking for over $200,000 in damages.

Continue reading "Man Sues CVS for Pharmacy Misfill" »

According to recent news that our Washington D.C. pharmacy error injury attorneys have been following, the U.S. Food and Drug Administration (FDA) has committed to reduce medication mistakes by publishing a draft guidance by the end of this fiscal year. The FDA states that one third of medication errors, including 30% of errors ending in deaths that are reported to the Institute of Safe Medication Practices (ISMP), may occur as a result of drug labeling and packaging.

The FDA reportedly claimed that medication errors often happen as a result of names that look alike or sound alike, encoded numerals, failure to recognize active ingredients, dangerous medical abbreviations, and name length.

In a FDA workshop last month, Carol Holquist, RPh and director of FDA’s Division of Medication Error Prevention and Analysis reportedly claimed that guidance on these medication mistake issues is an important first step to developing a consensus to form new FDA regulations, which can take around 10-15 years.

The American Society of Health-System Pharmacists (ASHP)’s director of Medication Use Quality Improvement, Bona Benjamin, also reportedly told the workshop group that the ASHP’s 2007 recommendations for the FDA are still current—that human factoring should be applied scientifically to drug packaging and labeling, and barcode verification should be encouraged, as nearly 20% of hospitals are using barcode medication verification.

Continue reading " Forum Guidance Leads FDA to Help Reduce Medication Errors" »

In recent news that our Baltimore, Maryland pharmacy error injury lawyers have been following, a Texas woman filed a lawsuit against Walgreens last week, claiming that a pharmacist mislabeled her medication—a mistake the woman claims, that could have caused her wrongful death.

According to Jessica Soliz, a Walgreens pharmacist made a major pharmacy error when labeling her prescription for seizure medication. After Soliz picked up her prescription drugs from the pharmacy and began taking them, she reportedly became very ill. The prescription error wasn’t discovered until a nurse looked at the label, and realized that prescription was mislabeled to read that each pill contained 25 milligrams of Lamictal, when in fact each pill in the bottle contained 100 milligrams or the drug.

According to the FDA, the most common medication errors are due to wrong doses, incorrect drugs, or the incorrect administration of drugs. The Institute of Medicine reports that there are around 1.5 million medication error injuries that happen every year, with at least 7,000 deaths.

In Soliz’s case, Walgreens responded that they were sorry that this pharmacy error occurred. They stated that they take pharmacy safety seriously, and are constantly working to improve the quality, accuracy and service of all pharmacy orders, to prevent pharmacy error injury or wrongful death.

Continue reading " Woman Sues Walgreens for Seizure Medication Pharmacy Error" »

Researchers from the University of California, San Diego recently published a study in the June issue of the Journal of General Internal Medicine, examining the myth of the “July Effect”—a legend that considers July a dangerous month for hospital patients to undergo treatment.

The study found that fatal medication errors in hospitals are at their highest in July, especially in teaching hospitals. July is reportedly the month when recent medical students graduates report to residencies in teaching hospitals and are given new responsibilities for patient care.

In their research, Dr. David Phillips and Gwendolyn Barker studied the relationship between medication error and inexperience in July, when thousands of medical residents begin their residencies. The research focused on the changes in the total number of medication mistakes; which includes medicine given and taken in error, accidental drug overdose, accidental medication errors in medical and surgical procedures, and drugs taken accidentally.

The study inspected 244,388 death certificates across the country, focusing on fatal medication errors that were recorded as the primary cause of death between 1979 and 2006—comparing the July death numbers with the number of events that are expected in any month in any year.

Continue reading "“July Effect” Study—Report Suggests July is the Worst Month for Fatal Medication Errors" »

In a highly publicized pharmacy error case from last year that our Washington D.C. Pharmacy Error Attorneys covered in a blog, 21 Venezuelan polo team horses tragically died after being given a drug mixed by Frank’s Pharmacy Compounding Lab, aimed to replicate Biodyl, a vitamin and mineral supplement that is often used to treat muscle fatigue in horses. The drug concoction was allegedly too strong, causing a medication error that lead to the death of the horses at the International Polo Club of Palm Beach in Florida.

This week, Franck’s Pharmacy voluntarily suspended all veterinary compounding in the lab, after reportedly being threatened with an injunction by the U.S. Food and Drug Administration (FDA). Last month, the FDA filed a complaint that Franck’s was going around the law by producing and selling misbranded and adulterated drugs and pharmacy compounds that were too similar to drugs that are FDA-approved.

According to the FDA, compounded drugs are not reviewed by the FDA for effectiveness and safety. Drug compounding has been criticized for lack of oversight—especially when both human and animal patients could be exposed to unapproved medication, that could result personal injury or even in this case death. In an FDA Compliance Policy Guide from 2003, the agency stated concerns about the risks posed by pharmacists and veterinarians who manufacture, distribute, and mass-markets animal drugs that are unapproved.

The FDA has reportedly had a strong interest in this case, as the deaths of these horses were caused by pharmacy error—from the same pharmacy that produces drugs for humans.

Continue reading "FDA Accuses Franck’s Pharmacy of Illegal Compounding" »

In a recent blog, our Washington D.C. Pharmacy Error Attorneys discussed the U.S. Food and Drug Administration’s (FDA) push for a broad recall of over-the-counter (OTC) products by Johnson & Johnson (J&J) in January—in an effort to maintain the health and safety of the consumer and to prevent OTC medication errors, after customers complained of moldy, musty smells in the drugs, that were caused by trace amounts of a chemical used when shipping the products.

The FDA announced this week that the administration has pushed J&J to begin another recall of certain children’s OTC liquid medicines—because of reported manufacturing deficiencies and violations found by federal health regulators during a routine inspection at a drug facility in Washington Pa—that could affect the quality, purity and potency of the products.

According to the FDA and the J&J unit, McNeil Consumer Healthcare, consumers should stop using all unexpired lots of both children’s and infant’s Tylenol, Zyrtec, Benedryl, and Motrin, because some the drugs reportedly may contain a larger concentration of the active drug than specified on the package. The recall also includes products that may contain inactive ingredients, other potentially solidified product ingredients, or other manufacturing residues that could include particles like tiny metal specks—that may not meet the testing requirements.

McNeil stated although there is only a remote possibility for serious medical problems, consumers should stop using the drugs, to avoid personal injury or illness in children.

Continue reading "Second Major Recall for J&J—FDA Found Manufacturing Violations in Children’s OTC Drugs" »

In a recent news that our Baltimore, Maryland Attorneys have been following, doctors are reportedly increasingly leaving behind paper when prescribing medications, and depending more and more on electronic prescriptions, or “e-prescriptions”—in an effort to avoid pharmacy misfills and medication errors, along with hard-to-read doctor handwriting, or even prescription fraud, as our attorneys reported on in our last blog.

E-prescribing immediately sends the prescriptions to the pharmacy in a digital format through a secured Internet network, from a handheld device or from their computers. The doctor simply selects the drug from a computerized list, with other symbols indicating the best drug option, different dosages, and either generic or name-brand medicine, instead of hand-writing the prescription, which can lead to medication error. Some e-prescribing programs give symbols in the form of colored or smiling faces, delineating between cheapest, preferred, or less desirable drug options.

According to the Wall Street Journal, the number of e-prescriptions almost tripled last year, from 68 million in the previous year, to 191 million in 2009. Surescripts, LLC, the company that handles the majority of the electronic communications in e-prescribing, reports that this represents 12% of the 1.63 billion original prescriptions, which excludes refills. The first three months of this year showed that one out of every five prescriptions is being filed electronically—a number that is rapidly growing, as nearly 25% of doctors based in offices already have the technology to e-prescribe.

In a study published in the Journal of General Internal Medicine in February of this year, e-prescribing was found to reduce common hand-written prescriptions errors significantly, including pharmacy misfills containing the wrong dosage, or incorrect usage instructions that could lead to patient injury or even wrongful death.

Continue reading "Study Shows E-Prescribing Significantly Reduces Prescription Errors" »

In a blog from last week, our Washington-D.C. area Pharmacy Error Attorneys at Lebowitz and Mzhen covered the topic of illegal prescription drugs, after a Maryland pharmacist was sentenced to federal prison for selling illegal painkillers to a drug dealer—drugs that were meant to be used under the supervision of a doctor, that could lead to personal injury, drug overdose and death.

According to the Baltimore Sun, prescription drugs are currently the number one cause of death overdose in the country. The Office of National Drug Policy claims that in his past year of drug abuse, prescription pain killers now rank second, behind marijuana as the nation’s most prevalent illegal drug problem. The National Institute of Medicine reports that 20 percent of people in the United States have used prescription drugs for non-medical reasons, leading to addiction.

In a recent Hollywood tragedy, Corey Haim, star of the 80’s film The Lost Boys, died in what officials from the Los Angeles Police Department claim was an accidental overdose of prescription drugs. After an investigation, Haim’s name surfaced in connection with an illegal prescription drug ring in Southern California with the painkiller OxyContin. The drug ring was linked to as many as 5,000 prescriptions—by ordering prescription pads from authorized vendors and stealing doctors’ identities.

Prescription drug overdose has been ruling news headlines over the past few years, after deaths of high profile celebrities like Michael Jackson, Heath Ledger, Anna Nicole Smith.

Many addicts are reportedly getting their prescriptions drugs by “doctor shopping," or going from doctor to doctor to collect prescriptions. According to the Sun, Maryland needs a system to monitor the number of prescriptions that are written for every patient, which if abused by "doctor shopping" can lead to medication error and injury. The Sun calls for Maryland Legislators to set up a drug task force to better monitor and control this drug epidemic.

Continue reading "Hollywood Prescription Drug Abuse —Illegal Drug Rackets and “Doctor Shopping”" »

In a recent article from the New York Times that our Washington D.C. Pharmacy Error Injury Attorneys have been following, U.S. doctors who have written over four million nitroglycerin tablet prescriptions, the drugs frequently used to reduce chest pain and stop heart attacks, have recently discovered that a large percentage of the drugs that have been sold to patients have not been approved by the Food and Drug Administration (F.D.A.) for sale, safety, or effectiveness.

According to the article, many doctors have recently discovered that their patients were given unapproved heart medication tablets, and they are unable to know whether the patients have experienced suffering, or any unnecessary personal injury as a result of the unapproved drugs. Dr. Harry M. Lever from the Cleveland Clinic claimed that if angina patients took nitroglycerin tablets that were possibly ineffective or substandard, they may not experience a diminishing of the pain, and the heart problem could lead to a heart attack, or wrongful death.

Nitroglycerin is regularly prescribed for relieving chest pain that comes with coronary artery disease. When the tablet is placed under the tongue, the medicine dissolves into the bloodstream quickly and dilates the coronary artery, which can decrease blood pressure slightly and reduce the heart’s exertion. When patients take nitroglycerin at the first signs of chest pain, cardiologists claim that heart attacks can be prevented.

The F.D.A. sent letters last week to two major nitroglycerin drug makers, Konec Inc., and Glenmark Generics Inc., warning them that they must stop selling the unapproved drugs. Although the F.D.A. claims that it has not examined the quality of the unapproved nitroglycerin products in question, it does have documented problems of other nitroglycerin products in the past.

Continue reading "Doctors Discover Millions of Patients Got Heart Pills Unapproved by F.D.A." »

In yesterday’s blog, our Baltimore, Maryland Medical Mistake Attorneys discussed leading causes of medical mistakes with children in this country, and important ways to prevent medical errors from happening.

According to the Massachusetts College of Pharmacy and Allied Health Sciences, 88% of medication errors involve the wrong dosage or incorrect drug. The Agency for Healthcare Research and Quality (AHRQ), the lead Federal agency that supports research to improve the quality of healthcare, addresses the importance of patient safety and the cause of many medical errors in a recently published press release.

In the press release, the AHRQ addresses the large problem of medical mistakes with children in this country, and gives parents and guardians tips on how to prevent these medical errors from happening with children, to avoid personal injury.

According to the AHRQ:

• Being involved in your child’s healthcare is the most important way to prevent medical errors or pharmacy misfills. The AHRQ stresses that it is extremely important for parents or guardians to take part in every decision that is made regarding the healthcare for a child.

• Make sure that your child’s doctors know every detail regarding the history and statistics (height and weight) of your child, every prescription, all over the counter medications, and any vitamins or dietary or herbal supplements, as well as any known allergies to any medication.

• At least once a year, bring a bag of everything your child is taking and go through each one with the doctor to ensure that there is no problem or conflict with any medication.

• Make sure you can read every prescription that the doctor writes. Double check the name and dosage, or if there is any question, have the doctor re-write the prescription in capital letters, printing the name of the drug and the dosage. If you can’t read the doctor’s handwriting, chances are the pharmacist will not be able to either.

Continue reading "AHRQ Tips for Preventing Medical Mistakes with Children" »

In our last blog, our Maryland Attorneys from Lebowitz and Mzhen, LLC, discussed a recent pharmacy misfill, where an 8-year old boy received the wrong dosage of a medication that could have caused the child serious personal injury or even wrongful death.

According to the Agency for Healthcare Research and Quality (AHRQ), medical errors are one of the leading causes of injury and death in this country. The AHRQ reports that in a recent study, rates for potential adverse drug events in hospitals were three times higher with children than adults, with an even higher rate for infants in intensive care units.

The National Coordinating Council for Medication Error Reporting and Prevention, (NCCMERP), estimates that nearly 98,000 people experience death from medical errors that occur in hospitals every year. Medication errors can happen at any point in the healthcare process and system and can result in injury—from miscommunication with doctors, to prescribing the drug, dispensing drugs at the pharmacy, or in the administering or the process of monitoring the drugs.

The AHRQ recommends that single most important way to prevent medical errors from happening to your child, is to be an active participant with the healthcare team that is caring for your child. Research shows that parents who are involved in all aspects and decisions of a child’s care experience better and safer results.

Continue reading "Keeping Children Safe—Eliminating Mistakes from the Children’s Healthcare Industry" »

In a recent lawsuit that our Maryland Pharmacy Mistake Lawyers have been following, a hospital is being sued for dispensing an overdose of pain medicine to a 68-year old woman, which allegedly led to her wrongful death.

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.

Continue reading "Lawsuit Accuses Hospital of Medication Mistake and Wrongful Death" »

Johnson & Johnson (J&J) has recently recalled certain lots of Tylenol, Rolaids, Benadryl and Motrin, after consulting with the U.S. Food and Drug Administration (FDA). McNeil Consumer Healthcare, the J&J subsidiary that sells the drugs, is voluntarily recalling the lots of the Over-The-Counter (OTC) products, in an effort to maintain the health and safety of the consumer and to prevent OTC medication errors.

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.

Continue reading "FDA Pressures Johnson & Johnson for Broad Recall of OTC Drugs" »

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 Maryland news this week, our medical mistake lawyers have been following the recall announcement by Sanofi-Aventis, the vaccine manufacturer of 800,000 doses of H1N1 vaccine for children under the age of three. According to the Washington Post, the flu vaccine has lost potency after being shipped from the factory, and doses are being recalled in Maryland and nationwide.

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.

Continue reading "Childrens' Doses of Swine Flu Vaccine Recalled in Maryland" »

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 a post from earlier this year, our attorneys at Lebowitz & Mzhen, LLC discussed how computerized health records would help Maryland pharmacists and doctors to eliminate Maryland medication mistakes.

According to a recent article in the Wall Street Journal, on how to digitize the health-care industry, Veterans hospitals have proven to have paved the way——showing doctors and pharmacists important lessons on how to effectively make the digital transformation.

The U.S. Department of Veterans Affairs digitized their records years ago, with great results. Independent studies show that the VA outperformed the private sector and Medicare on preventative services and chronic care. VA officials have claimed that the digital technology has helped cut down on patient hospitalizations and has helped patients live longer.

The VA’s digital records system has been a blessing to patients, allowing doctors and nurses at more than 1,400 facilities to share the medical history of the patients—avoiding the unnecessary repetition of costly tests. As well as storing patient data, the system gives screening warnings and keeps an eye on patient levels, like blood pressure and weight—all safeguards for improved quality care.

In a digitized record for a 59-year old Maryland patient at the VA medical center, all of his health problems were listed, like diabetes and hypertension, as well as all of his data since he has been a patient at the center. The screen showed a list of all current medications, including insulin, the drug Furosemide for heart failure, and Oxycodone, the pain medication. The patient’s doctor can reorder a drug through the system, sent directly to the pharmacy—eliminating medication mistakes and pharmacy misfills. If the doctor orders a new prescription that conflicts with a drug the patient is already taking, there is a warning in the system.

Continue reading "Veterans Hospital Paves the Way for Computerized Records" »

A recent American Pharmacists Association (APhA) survey, that our Maryland Pharmacy Error Injury Attorneys have been following, revealed that 1.5 million people are injured by medication-related errors every year. The APhA commissioned the consumer survey, led by Harris Interactive, to investigate how consumers interact with their pharmacists, and how building relationships with pharmacists can avoid patient error and reduce medication mistakes and pharmacy misfills.

The APhA always recommends that people carry an updated list of their current prescription medications, over-the-counter (OTC) drugs, herbal supplements and vitamins. The list should include the name of the medications, the dosage, as well as the conditions that the medications treat. Any patient allergies should also be included in the list.

The study reports that while a large percentage of Americans have an up-to-date list of medications, only 28% of consumers actually carry the list with them at all times—an act that could prevent personal injury and medication mistakes, by providing emergency personnel and pharmacists with lifesaving information regarding drug names, proper dosing, allergy information, and drug interactions and side effects.

According to Kristen Binaso, pharmacist and national APhA spokesperson, until electronic medical records are used as the standard in sharing patient information in the health care industry, consumers should protect themselves by keeping a current medication list with them at all times, to show the doctor and pharmacist—to avoid the risk of improper dosing, medication duplication, pharmacy misfill, and harmful drug side effects and interactions. In a recent post, our Maryland Mistake Attorneys further discussed how these electronic health records will help pharmacists and doctors to eliminate medication errors.

Next to doctors, pharmacists are the second most trusted health care providers and trained medication experts, yet the survey found that 77% of consumers do not know their pharmacists names, and only 40% of consumers have asked their pharmacists valuable questions about their medication needs.

Continue reading "Medication Error Injury Prevention—Study Recommends Knowing Your Pharmacist" »

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