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Medication error has been a leading cause of harm for patients, and an expensive cost for healthcare providers. In a digital age, some healthcare providers have implemented digital solutions to medication errors, but these digital solutions can cause doctors to receive too many alerts that lack specificity and that also cause alert fatigue for doctors. However, when science and technology combine to create a unified and efficient approach for drug administration and managing clinical decisions, it can be life-altering. A Healthcare IT News article details the importance of hospitals integrating precision medicine with digital maturity models. The digital maturity models can help technology advances that support clinical decisions. This can help prevent errors and increase efficiency, which thus can save lives and costs for hospitals. Giving users access to a single information source in a unified approach can help with drug administration and minimize alerts.

What Is a Digital Maturity Model?

Some examples of digital maturity models include from Wolters Kluwer, which built Medi-Span Clinical APIs drug data solution and expert services which helps ensure that accurate information is available at key moments rather than reported after the event, and also ensures the precision of alerts. Another example is the National Chen Kung University Hospital in Taiwan, which has used Medi-Span Clinical APIs to overcome challenges faced by pharmacists, including the challenge of the amount of time it takes to update a medication database. Medi-Span’s databases are updated regularly with best practice evidence and recommendations. Clinical APIs are for healthcare professionals only, and there are certain regulations that guide their use in various locations.

The hospital’s data shows that since implementing Medi-Span, the number of alerts has been reduced by 21% and the talerts have captured severe potential Adverse Drug Events. This resulted in saving approximately $39,200 in U.S. dollars a year, and also saved an estimated 266 bed days a year. Technology advances can allow for solutions that help prevent medication errors and help ensure that patients receive the best and safest care possible. When these errors occur but can be avoided by digital maturity, it is up to hospitals to implement unified approaches to avoid such costs.

Feeding tubes can be an essential tool used to administer medicine to patients who need it. People who have difficulty swallowing or difficulty feeding may need enteral feeding tubes. Although an essential tool, more must be done to prevent errors that occur when preparing and administering medications via enteral feeding tubes. Enteral feeding tubes allow liquid food to enter the stomach or intestine through a tube. Enteral feeding tube errors occur for a variety of reasons, including gaps in training, incorrect tube or route size, improper preparation, and utilization of the wrong administration technique.

What Are the Causes of Feeding Tube Mistakes?

In some instances, practitioners have not received the proper training associated with prescribing, verifying, prepping, and administering specific medications through feeding tubes. Knowledge may be passed down from practitioners, but there may lack a standard policy for doing so to ensure that there are no gaps in knowledge. Additionally, there are errors that occur if a prescriber selects an incorrect route, such as selecting the oral route of administration for a patient who actually requires medication via an enteral feeding tube. Improper preparation can result in adverse reactions for the patient and the practitioner. In these scenarios, if a practitioner fails to use proper personal protective equipment (PPE) and crushes a hazardous medication, this can result in toxicity or reduced efficacy of the medication. Additionally, error also occurs if the wrong administration technique is used. This includes mixing multiple medications together to give to a patient at once, failing to flush the tube before and after medication administration, and mixing medications with enteral feedings.

In order to prevent these errors, practitioners should screen for enteral feeding tube restrictions, create policies that are located in a central location for reference, and should ensure that practitioners are properly educated on how to safely prepare and administer medication. In addition, because patients will often follow the same procedure to prepare and administer medications at home, it is important to educate patients about safe practices. If you have reason to suspect that a loved one has suffered injuries due to error that occurred during the administration of medication via an enteral feeding tube, contact an experienced and skilled medical malpractice attorney today to discuss your options.

When it comes to our prescriptions, we count on pharmacies to get it right. Instructions scribbled by doctors on notepads or hurriedly said by nurses and office staff while we check our calendars for follow up appointments or scrutinize our bills are hardly reliable. Instead, checking and double-checking pill bottles or printed pharmacy instructions before consuming prescription medication is often the safeguard patients use to ensure they’re not over or under consuming their prescribed drugs. When these instructions are wrong, the results can be catastrophic.

What Are the Potential Harms of a Medicine Dosing Error?

According to a recent report, a prescription for alirocumab, a drug to prevent cardiovascular events, was marked with erroneous directions. The pharmacy instructed the patient to inject “1 mg,” or one milligram, under the skin every 2 weeks. But the actual instructions were supposed to be injection of one milliliter. The instructed dosage would have been confusing and impossible to measure for a patient. While this error was fortunately realized by the patient due to the difficulty in measuring one milligram, other such errors—like transcribing a number incorrectly—could result in over or under-consumption of medications, which can lead to overdose or prolonged illness.

In this case, the error occurred because the verification by two pharmacists failed to catch the mistake. Some pharmacies do not have processes for typing directions, even though these medications should often be administered in a standardized way. Doctors provide varying instructions, and pharmacies often follow the doctors’ instructions verbatim or close to it, without verifying the units and dosage against standards for the medication. The prescription in question would have also been easier to understand had the pharmacist instructed the patient to inject one entire pen, rather than 1 milliliter or milligram, as the pen was designed to hold one dose. Pharmacies can also employ more checks to ensure patients understand how to use medications, like asking patients to repeat instructions back and confirm dosage.

After a long period of lockdown, demand for COVID vaccines and boosters has been high. At times, the demand has exceeded both the supply of vaccines and pharmacies’ capacity to administer them. Unfortunately, when a pharmacy accepts a high volume of patients without increasing its capacity and hiring more staff, it can result in errors and mix-ups. These errors in vaccine administration have the potential to be fatal.

As a recent news article reported, a woman received the incorrect COVID vaccine booster at a Walgreens pharmacy in Rutland, Vermont. The woman received the vaccine after making an appointment for the “newest, most updated” COVID booster. Two days after her appointment, she received a call from the pharmacy informing her they had mistakenly administered an older version of the booster. The pharmacy employee told her she was still protected from COVID; however, the booster would not protect her from the newest strain. Luckily, the woman did not suffer any medical issues from the mix-up. However, given the potential for a more dire mistake, she filed a complaint with Walgreens’ corporate offices. After doing so, she claims she received an indication that other people had also received the wrong vaccine, though Walgreens denies that it happened to anyone else at the Rutland location.

Notably, the Vermont Office of Professional Regulation filed a complaint in June 2022 seeking to revoke or otherwise discipline the licenses of 32 Walgreens stores in the state, including the Rutland pharmacy. In fact, in its complaint, the Office reported that unsafe conditions at the pharmacies have increased the risk of prescription errors, vaccine administration mistakes, and the risk of harm to patients. Allegedly, Walgreens’s vaccine scheduling site had allowed such high volumes of appointments that staff could not keep up with the demand. According to the complaint, these issues resulted in the pharmacy’s inability to safely administer vaccines.

Patients seeking medical care have certain standards and expectations for what they will receive when getting treatment. When those standards are not met, the consequences can be dire. For patients whose lives are on the line, one small mistake from a doctor, nurse, or pharmacist can have an enormous impact.

Recently, a woman picked up what she thought was cancer medication from her local pharmacy. She took the prescribed pills for two months before realizing that she had actually received anti-cholesterol medication from the pharmacy instead of the medicine she intended to be taking. The woman’s doctor had prescribed her a drug called exemestane, but the pharmacist had failed to check the medication bottle and had given her something called ezetimibe instead.

Apparently, the pharmacists providing the medication failed to properly dispense the prescription. The pharmacy was supposed to have a three-step process for ensuring that each patient’s medicine was what they were expecting to receive: a check when the medicine was selected from the shelf, a second check when the dispensing label was put on the container, and a third check when the prescription was given to the patient.

After almost two years since COVID-19 vaccines become available, there are still concerns regarding avoidable administration errors that result from labeling and communication errors. When we walk into a doctor’s office to receive vaccines, we trust that we will receive the correct vaccination. But when administration errors occur for various reasons, it is important that these errors are accurately reported and that steps are taken to prevent these administration errors from happening again.

According to a recent news report, one current problem involves the labeling of the Moderna vials for the primary series for ages 6 to 11 years of age, which are still labeled as “for booster doses only.” Despite the label, these are not used for booster doses. In addition, there are two different Moderna vaccine vials that have a similar dark blue cap, which could result in an error if the vaccines are stored close together. The labeling includes the word “bivalent”, which may be more difficult to see on the Pfizer booster dose for ages 12 years and up, while compared to the Moderna label which may feature the word “bivalent” more clearly on the label. The word “bivalent” is essential to distinguish between the monovalent vaccine.

According to an interview involving the president of the Institute for Safe Medication Practices (ISMP), which was shared by Pharmacy Practice News, ISMP has received messages via Linkedin, phone, and email regarding how the labels appear to be so similar and regarding the difficulty of seeing the word “bivalent.”

People that regularly take prescription medicine or have received prescription medication in a hospital or clinic setting can appreciate the vital importance of best practices when it comes to receiving medicine. Whether it is at the pharmacy or in the hospital, it is essential to be aware of safety measures that could make a major difference in the care you receive. Every patient deserves peace of mind when it comes to their medications, and to live free of the consequences of medical and pharmaceutical malpractice.

How Common Are Medication Mistakes?

Incorrect or erroneous distribution or application of medications is surprisingly present in the United States. In fact, some sources cite a rate of one in five Americans experiencing a medical error while receiving health treatment. Unfortunately, Maryland is no exception to this trend, and Maryland residents should be aware of emerging best practices in the face of the increased computerization of pharmacies and hospital medication cabinets.

Emerging Best Practices to Reduce Harm

The process of receiving medication involves a lot of different moving pieces, and as providers complete their various tasks so that a patient may receive their proper medication, medication errors unfortunately can happen at any stage. Medication errors can involve errors in various stages of the process of ordering or delivering medication. For patients who are medically in need of specific medication to help their condition, and for patients who aren’t necessarily in dire need of their medication, but find themselves on the receiving end of a medication error, the consequences can be devastating.

What Can Happen After a Medication Error?

Medication errors can lead to serious injuries and can lead to adverse reactions. Medication errors can range from receiving the wrong dose, the wrong frequency, and the wrong drug, in addition to the wrong-patient medication error. However, when an incident report is filed and labeled as a wrong-patient error in medication administration, what exactly does that entail? It has been particularly unclear if wrong-patient errors for drug administration involves the wrong-patient receiving a medication intended for someone else, or if the intended patient received the wrong drug. A recent and eye-opening study sought to clarify the meaning behind “wrong-patient” errors in drug administration.

A study was recently published in August 2022 on DovePress, which features peer-reviewed journals in science, technology, and medicine. In this study, researchers investigated wrong-patient medication errors in incident reports that were voluntarily reported by medical staff at a university hospital in Japan. Specifically, the study investigated whether the patient or the drug had been incorrectly chosen in drug administration in incident reports that included wrong-patient errors. The results revealed a few things. First, the study included a total of 4,337 incidents that were reported between April 2015 and March 2016 at a particular hospital in Japan, and medication-related incidents were the most prevalent. According to the study, “[o]f the medication-related incidents, the largest number of incidents occurred at the medication administration stage…”. Evaluators determined “that cases where the intended drugs were administered to incorrect patients occurred less frequently than cases where the wrong drugs were administered to the intended patients.” In essence, this means that the study found that there were more mix-ups involving patients who received a different medication than what they were supposed to receive because there was some kind of mix-up with the type of medication administered (the patients were receiving the wrong drugs, versus situations where the right drugs mistakenly go to the wrong patient).

In an ever-changing scientific field, as new information and knowledge are gained each day, there may be important updates regarding your medications. For this reason, it is important to stay in touch with your healthcare providers about possible changes. In August 2022, the Food and Drug Administration (FDA) issued a warning to patients, caregivers, and health care professionals regarding autoinjector devices and their compatibility for use across FDA-approved glatiramer acetate injection drug products. Glatiramer acetate injection is used to treat relapsing forms of multiple sclerosis. There are three FDA-approved glatiramer acetate injection drug products on the market currently. These drug products are all available in a single-dose prefilled syringe with an attached needle, and patients can inject glatiramer acetate using only the syringe or by inserting the syringe into an autoinjector. Autoinjectors are medical devices designed to support patient self-injection of medication.

The FDA announcement lays out the three FDA-approved glatiramer acetate injection drug products and its compatible autoinjector device that is optimal for its use. According to the announcement, the drug product titled “Copaxone”, manufactured by Teva Pharmaceuticals is compatible with Autoject 2. The drug product titled “Glatopa”, manufactured by Sandoz, is compatible with the Glatopaject autoinjector device. Finally, the drug product titled “Glatiramer Acetate Injection”, manufactured by Viatris/Mylan, is compatible with WhisperJECT autoinjector device. The FDA has requested that the manufacturers update their labeling to instruct users to confirm that the autoinjector is compatible before using it to inject glatiramer acetate. Overall, patients, caregivers, and health care professionals should be sure to confirm that their autoinjector is compatible, and manufacturers should update their labeling to advise patients as such. Failure to do so can and has resulted in missed and partial doses.

What Happens if Drug Manufacturers Fail to Properly Label?

Drug manufacturers have the responsibility of following the regulations placed on medications by the FDA. The FDA requires that drugs go through testing before they are FDA approved, and manufacturers must comply with medication labeling regulations. Because there are various regulations and laws that may be applicable depending on the jurisdiction, the type of drug, whether the drug is brand-name or generic, etc – it is important to connect with an experienced attorney who can help you navigate your case. If you have suffered injuries as a result of negligent drug manufacturing companies, connect with a lawyer today to discuss the details of your case.

Having to visit a medical center can be nerve-wracking because there may be a lot of unknowns, including what kind of quality of care you will be provided. Whether a hospital has had multiple pharmacy errors or other dangerous incidents at the hospital can be particularly important for patients and potential future patients to know.

According to a recent news article, a medical center in California faced the risk of losing its Medicare funding after state inspectors uncovered multiple dangerous incidents regarding proper drug distribution. In one incident, an 88-year-old woman was hospitalized for chest pain, and instead of receiving medication for her symptoms, she was mistakenly given two doses of a chemotherapy drug used to treat breast cancer, a condition that family members say she didn’t have. According to the patient’s daughter, a nurse dismissed the daughter’s concern that after being admitted to the medical center, at one point, she could not understand her mother over the phone and thus told the nurse that it sounded as if her mother had suffered from a stroke. Because of this growing concern, the patient’s daughter called the nurse the next day and requested the list of medications that had been prescribed for her mother. The woman died less than a month after being admitted to the medical center. In a confidential report, the state’s public health inspectors stated that the medication error “could potentially cause harm or serious adverse drug reactions to the hospital’s patients.”

In addition, in another incident at the same hospital, a patient with dementia and a history of falls attempted to walk unassisted in his room and tripped over a device. As a result, the patient suffered a fractured hip and was found on the floor by a nurse. According to the article, an alarm designed to prevent such falls by alerting staff when a patient leaves a bed had not been turned on. Doctors decided not to repair the patient’s help because of their belief that the surgery was unlikely to improve his quality of life, and that patient was placed on comfort care and died 7 days after the accident.

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