Settlement in Hospital Pharmacy Case Demonstrates Weaknesses in Systematic Checks

Hospital pharmacies, as opposed to retail pharmacies, present unique challenges that can lead to mistakes being made. Those include a much larger amount of patients being served at any given time, more complicated health issues or treatments, different doctors providing coordinated care, and the different medical professionals’ habits in writing prescriptions and delegating tasks to others. blue%20white%20pills.jpg

In one case (login required), which eventually prompted a malpractice lawsuit, there was some confusion when a doctor initially wrote a prescription for 10 units, and after deciding to increase the dosage, rather than writing a fresh prescription, he wrote a 2 over the 1, in an attempt to indicate 20.

What happened next, however, demonstrates what can, and does, happen in practice. The nurse practitioner who had walked in as the doctor was writing the prescription, did not know what dosage the doctor had intended, and when she found it in the patient’s file, had difficulty discerning what the doctor had intended. After conferring with the pharmacist for several minutes, and stating that they both saw a 1 and a 2, they concluded that the prescription must have been for 120 units. The prescription for 120 millimoles was filled for the patient, and the prescription was filled and administered to the patient. The nurse practitioner left, since her shift had ended, and when she returned the next day, the patient had died.

As a result of the incident, the nurse practitioner and pharmacist were both suspended pending an internal investigation. While the doctor admitted to having messily written the prescription, he also faulted the nurse and pharmacist for not realizing that the 120 dose of the medication would be fatal, and not contacting him for clarification.

The claims against the hospital were settled outside of court, and resulted in the termination of the pharmacist and nurse practitioner. The case against the doctor went to trial, which resulted in a finding that the doctor was only 10% liable. However, since the suit had not named the pharmacist and nurse practitioner, evidence regarding their errors was not relevant to the determination of the doctor’s fault.

The problem demonstrated in this case is that hospital employees are hesitant to question what they perceive as the prescribing doctor’s intentions. In this case, for example, both individuals stated that they didn’t want to bother the doctor by seeking a clarification. Additionally, it was not reported whether the dosage was actually considered, such as being looked up in order to determine the appropriateness for the patient. While errors like this one are understandable, they are still unacceptable. In this case, the patient was admitted for a foot amputation, but instead ended up being killed.

If you or a loved one has been injured or died as a result of a medication or pharmacy dispensing error, contact the experienced Maryland prescription error attorneys at Lebowitz & Mzhen, LLC. Whether you or a loved one were harmed by medication that was improperly prescribed, dispensed, or administered, or you suffered as a result of medication side effects, contact us today in order to schedule your initial complimentary consultation. You can reach us by calling (800) 654-1949 or through our website, in order to schedule your complimentary initial consultation.

More Blog Posts:

Compounding Pharmacy and Drug Maker at Center of Contamination Lawsuit, Pharmacy Error Injury Lawyer Blog, published December 12, 2013
Court Sides with Plaintiff in Expert Testimony Prescription Medication Injury Case, Pharmacy Error Injury Lawyer Blog, published December 5, 2013

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