Recent Hospital Pharmacy Error Was a Result of System-Wide Failures

Earlier this month, a man in a New Zealand hospital died due to opioid toxicity after he was administered what turned out to be a fatal dose of fentanyl. According to a local news report covering the story, the error was a result of system-wide failures across the spectrum of care providers.

SurgeryThe victim of the error was at the hospital for a routine knee surgery. The hospital had just implemented a new e-prescribing system the month before, whereby physicians could order medication at a patient’s bedside with one touch on a computer screen. The physician overseeing the victim’s care was attending to another patient when he remembered to put in an order for the victim’s medication. The physician input the medication order and then returned his attention to the other patient.

The physician, however, failed to switch the computer screen back to the patient who was with him. Thus, when the physician entered a medication order for fentanyl patches that was intended for the other patient, the order was sent to the victim’s file.

The pharmacist on duty received the order for the fentanyl patch. The specific strength of patch prescribed was the strongest patch available. Nonetheless, the pharmacists overrode 22 different alerts and warning messages and filled the prescription.

The patient was given the patches, and his condition quickly began to deteriorate. However, attending nurses failed to notice that his hands were cold, his pulse had slowed down, and he was breathing in a shallow manner. Shortly afterward, the patient was pronounced dead.

As it turns out, there were several other instances in which a diligent caretaker could have noticed an error had occurred. For example, the physician who inadvertently prescribed the fentanyl patch later that day received a phone call informing him that the patient for whom the fentanyl was supposed to be prescribed had no medication orders on file. Thus, had the physician been diligent, he may have realized that an error may have occurred and looked into the matter.

Additionally, when the physician returned to the hospital after the error but before the patient’s symptoms set in, he noticed that the patient had a fentanyl patch. However, that did not trigger a red flag for the physician because he believed that the patient had previously been prescribed fentanyl patches before arriving for the knee surgery.

Have You Been a Victim of a Hospital Pharmacy Error?

If you or a loved one has recently been a victim of a Maryland pharmacy error, you may be entitled to monetary compensation. In some cases, cases involve claims of both traditional negligence as well as medical malpractice. In these situations, it is important that plaintiffs consult with a Maryland injury attorney who is skilled in both of these complex areas of the law. At Lebowitz & Mzhen, LLC, we have decades of experience handling medical malpractice and pharmacy error claims, and we know what it takes to succeed on our clients’ behalf. Call 410-654-3600 to schedule your free consultation today.

More Blog Posts:

Woman Given Ten Times the Prescribed Dose of Epilepsy Medication Suffers Permanent Symptoms, Pharmacy Error Injury Lawyer Blog, March 21, 2018.

A Look at Hospital Pharmacy Errors, Pharmacy Error Injury Lawyer Blog, April 2, 2018.

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