Advances in Patient Safety

“Good Catch” Program Hopes to Encourage the Reporting of Pharmacy Errors Before They Occur

September 20, 2011 | Lebowitz & Mzhen

A system developed at Johns Hopkins Medicine in Baltimore, Maryland intends to prevent accidents before they happen by encouraging clinicians to report situations that might lead to dangerous or even life-threatening incidents for patients. Known as the “Good Catch Awards,” the program distributed 27 honors in its first two years for reports that led to positive changes in patient safety. Such changes ranged from modifications in pharmacy order sheets to a national recall of improperly-labeled drugs.

The “Good Catch” program operates on the theory that, instead of errors being attributable to one individual, most errors result from a flawed system in a hospital. It stresses to doctors and other medical practitioners that its purpose is to find solutions to common errors, not to assign blame for those errors. Not all doctors and others have embraced the system yet, but most acknowledge that it is a vast improvement over safety systems at most hospitals. Robert Stoelting, MD, president of the Anesthesia Patient Safety Foundation, compared the system to those used in nuclear plants and airlines, where the responsibility for safety is shared by everyone. He suggests the creation of a national database to collect hospitals’ self-reports of “errors and so-called near misses” in order to better share safety information and create greater opportunities to improve patient safety.

Other hospitals have implemented their own “Good Catch” programs, inviting clinicians to share examples of near misses that could have resulted in patient injury but did not. The University of Connecticut Health Center offers a “Good Catch” award for near misses that lead to improvements in patient care. The Minnesota Hospital Association awards a “Good Catch for Patient Safety Award” to clinicians “who demonstrate their commitment to keeping patients safe by ‘speaking up’ to prevent potential harm to a patient.” The Brantford Community Healthcare System in Brantford, Ontario, Canada solicits stories from its medical staff about incidents that contribute to its “culture of safety.”

Reducing Medication Error Injury by Keeping Health Record Journals

August 30, 2011 | Lebowitz & Mzhen

Our Prince George’s County, Maryland pharmacy error lawyer blog recently reported on the important role communication plays between patients and their healthcare providers—in order to reduce the risk of medication errors or pharmacy misfills, and to promote the safe and effective use of drug therapy.

Every year, 1.5 million Americans experience medication-related injuries, according to a study by the Institute of Medicine. In order to prevent medication errors, the American Pharmacists Association (APhA) reports that it is important for patients to keep accurate health records with them when visiting the doctor and pharmacist, including current prescription medication lists detailing the dosage information along with all health conditions that the medication is treating.

Patient medication lists can reduce the risk of pharmacy misfills, incorrect dosages, medication duplication, allergy interaction, and any harmful side effects from potential dangerous drug interactions. The APhA also states that by keeping drug lists with them at all times, patients can prevent medical error by providing emergency staff and hospital pharmacists with important information that could saves lives in an emergency.

According to a recent Chicago Tribune article, doctors are now recommending that individuals turn the medication lists into a comprehensive health journal, to keep healthcare providers informed and to prevent medication error injury.

Report Finds Medication Errors in Chronic Drug Therapy After Seniors Leave Hospitals

August 29, 2011 | Lebowitz & Mzhen

According to a recent study discussed in the Journal of the American Medical Association (JAMA), that our Baltimore medication error lawyers have been following, hospitalized patients are more likely to have medication errors than non-hospitalized patients—when drugs used to treat chronic conditions are unintentionally discontinued in hospitals, especially if the patients are in a hospital’s intensive care unit.

The study reportedly showed that transitions in healthcare can increase a patient’s chances for medical errors that stem from inaccurate or incomplete communication between the hospital staff, the primary care physician, and the patient—causing an interruption or discontinuation of medications that aim to help treat patients’ chronic diseases on a long term basis.

According to the authors, the problem of medication errors and the unintentional discontinuation of drugs can happen during hospital stays, transfers and discharge. Treatment in intensive care units can also increase the risk of medication errors of omission as the healthcare providers are focused on emergency care and may engage in the practice of discontinuing a medication used for chronic illnesses during a time of critical illness.

The medication error study followed nearly 400,000 patients who were older than 65, and who had over one year of experience continuously taking one of the following five drug classes: respiratory inhalers, gastric acid suppressors, statins, anticoagulant or antiplatelet agents, and levothyroxine, used to treat the thyroid gland.

Medical Error Leaves Judge with Surgical Sponge in Body

August 25, 2011 | Lebowitz & Mzhen

Our Baltimore medication error injury blog recently reported that according to the Institute of Medicine, 1.5 million medication error injuries occur every year around the country that are preventable, and as many as 98,000 deaths due to medical errors.

When Nelson Bailey decided to have elective surgery for diverticulitis, a condition causing him abdominal discomfort, he was told that he would be out of the Good Samaritan Medical Center in around four days. What Bailey didn’t expect, according to a recent article in the Sun Sentinel, was that he would suffer from two different and equally serious medical errors at the hospital that would change his live completely.

Bailey, a Palm Beach County judge, underwent the intestinal surgery in October 2009, where the surgeon made a medical error by mistakenly leaving a surgical sponge inside Bailey’s body—that was reportedly as big as a washcloth, and was left to fester for five months.

When Bailey was recovering from surgery he then experienced a hospital pharmacy error, after the pharmacy prepared the incorrect medication. The doctor had reportedly ordered blood pressure lowering medication, but when the wrong medication was sent from the pharmacy, the nurse gave him the drug without double checking the drug label.

New Palm-Vein Scanning Technology Introduced to Reduce Medical Errors in Hospitals

August 22, 2011 | Lebowitz & Mzhen

Our Hartford County, Maryland pharmacy error injury attorneys have been following the latest healthcare technology introduced by New York University’s Langone Medical Center, in an effort to reduce the amount of time it takes to check patients in to the hospital, and to eliminate medical errors.

As our lawyers have discussed in a previous Maryland medication error injury blog, according the Institute of Medicine, there are 1.5 million medication error injuries every year that are preventable, and as many as 98,000 deaths due to medical errors.

The new biometric technology aimed to improve patient safety is made by Fujitsu, the technology services company, and works with the concept that like fingerprints, every patient has an individual and unique palm-vein configuration. The technology uses near-infrared waves to take an image of a patient’s palm veins, which the software then links to that patient’s medical records in about a minute. Other reported benefits of the technology is that a patient does not have to be conscious during the check-in process, and the system eliminates the need for a patient to fill out any forms, unless the patient’s insurance has changed since the last palm scan.

The hospital reportedly experiences around 1.7 million patient visits per year, and is in the process of converting as many patients as possible to the new palm scanning system, to prevent medical errors and patient injury. Since 250 scanners were installed in June, over 25,000 patients have received palm-vein scans that have been registered in the system. The palm scan does not appear in the patient’s medical records, and it is not stored as an image. After the palm is scanned, the image is converted into special numeric code.

WHO Claims Hospitals Are More Dangerous Than Airline Travel

August 18, 2011 | Lebowitz & Mzhen

According to a recent report in Medical News Today that our Baltimore medical error injury attorneys have been following, Professor Sir Liam Donaldson has been appointed as the new Envoy for Patient Safety for the World Health Organization (WHO). Donaldson recently stated, in an effort to highlight the fact that healthcare safety around the world needs to be improved, that going to the hospital is far more dangerous than flying on an airplane, as the WHO reports that millions of people die annually from medical errors associated with healthcare—far more, according to Donaldson, than accidents on planes.

In his striking comparison, Donaldson claimed that if a patient entered the hospital he would have a 1 in 10 chance of experiencing a medical error, with the chances of wrongful death due to medical error being 1 in 300. Donaldson then stated that in comparison, the risk of dying in a plane crash is far less—approximately 1 in 10 million.

Donaldson reportedly stated that in an effort to reduce the growing number of hospital related infections resulting in patient injury or harm that happen every year, patients need to ask questions and make sure that hospitals maintain the basic hygiene standards and conform to the WHO’s healthcare checklist to prevent medical error or patient illness or injury during surgical procedures.

According to the WHO statistics, 7 in 100 patients in the hospitals throughout developed countries experience infections linked to healthcare, whereas in developing countries this number increases to 10 patients in every 100. The risk of infection is directly tied to the length of time a patient stays in the hospital’s intensive care unit. The WHO figures show that risk of infection is lower in the United States than in Europe, but the death from hospital-acquired infection is higher. In the United States, 1.7 million hospital acquired infections reportedly happen every year, resulting in 100,000 deaths, and in Europe, 4.5 million hospital acquired infections happen every year, resulting in around 37,000 deaths.

The Benefits and Problems of Electronic Medical Records Systems

August 10, 2011 | Lebowitz & Mzhen

In a recent Baltimore County pharmacy misfill injury blog, our attorneys discussed a tragic medical error that caused the death of an premature infant, after a pharmacy technician accidentally entered the wrong information into the computer, causing the intravenous solution prepared buy an automated machine to contain a lethal dose of sodium chloride. This pharmacy error has reportedly brought the issue of electronic medical health records safety concerns back into the forefront of patient safety.

As our attorneys have reported in a related Hartford County medication error injury blog, the medical industry is shifting toward electronic medical records and computerized systems that make medical processes and prescription orders automatic, in an effort to reduce pharmacy error injury or wrongful death.

The Chicago Tribune reports that the federal government is also currently helping the digital shift by giving $23 billion in incentives to healthcare providers who purchase the electronic systems, with the hopes that these medical technologies will help increase access to patients’ medical information, help healthcare providers communicate better with each other, help doctors to see test results more quickly, and implement electronic safeguards to remind doctors about recommended medical practices, or to alert them about harmful drug interactions before prescribing.

With all of the benefits that come with electronic medical records and computerized systems, potential problems are also taking place, like crashing of hospital computers, or software bugs that interfere with important data, or even delete information from computerized records. Computerized systems also reportedly can produce data about patients that is disorganized or difficult to read, especially when a doctor is quickly looking for critical patient information.

Risperdal Recalled by Manufacturer Due to Drug Contamination

July 29, 2011 | Lebowitz & Mzhen

Our Talbot County, Maryland pharmacy error injury lawyer blog recently discussed a series of recalls drug maker Johnson & Johnson made last year, in an effort to maintain the health and safety of consumers—after complaints of an unusual smell causing nausea, vomiting, diarrhea and gastrointestinal pain were reported, due to trace amounts of 2, 4, and 6-tribomoanisole (TBA), a chemical used to preserve wood necessary in the construction of pallets used for transportation and shipping of the product packaging materials.

In related news, Ortho-McNeil-Janssen Pharmaceutical, the drug manufactures of Risperdal (risperidone), an antipsychotic drug used for the treatment of schizophrenia, bipolar disorder, and irritability associated with autistic disorder in adolescents and children, recently voluntarily recalled 16,000 bottles of the brand name drug and 24,000 bottles of the generic drug—also because of an unusual odor.

The Risperdal drug manufacturers found that the unusual smell was also caused by trace amounts of TBA, used to preserve wood pallets for the transportation and storage of product materials. While not considered to be toxic, a small group of patients have reported gastrointestinal symptoms when taking products with this offensive odor. The drug maker claims that the presence of TBA has not caused any reported serious adverse events, but the company has instituted a series of actions to reduce the potential of TBA contamination in the future, to avoid personal injury or harm to any consumers.

This is the second medication error warning surrounding Risperdal this year. Last month our attorneys discussed another warning involving Risperdal in a Baltimore pharmacy error injury blog, issued by the U.S. Food and Drug Administration, discussing potentially dangerous medication errors associated with Risperdal and Requip, a drug used for the treatment of Parkinson’s disease and Restless Legs Syndrome, with 226 reports of patients receiving the incorrect medication.

Report Warns Consumers to Take Precautions With Drug Labels and Instructions

July 25, 2011 | Lebowitz & Mzhen

In a previous Baltimore medication error injury blog post, our attorneys discussed a recent investigation by Consumer Reports Health that found evidence of inconsistency among prescription drug labels for warfarin, a blood thinner. The report found that important safety warnings and medication guides that are required by the federal government in order to prevent medication errors, were often omitted or left out of patient’s warfarin prescriptions.

As our Maryland pharmacy mistake lawyer blog has reported previously, every year, according to research by the Institute of Medicine, there are 1.5 million preventable medication error injuries, one third of which take place outside of hospitals, where consumers must make their own decisions about following medication instructions. Consumer Reports Health suggests that these medication errors happen because consumers are confused by the material that is included with prescriptions, and that they rely heavily on the medication bottle label—a problem if there are omissions or inconsistencies with the drug label.

The report found the following discrepancies:

• Four out of five pharmacies neglected to provide the medication guides that are required by the FDA for certain drugs, including warfarin.
• All of the pharmacies provided their own materials for the patients, but these conflicted with the guides for warfarin approved by the FDA. The FDA recommended that patients abstain from alcohol while taking the drug, while two pharmacies warned patients that they should just limit or avoid alcohol usage.

Consumer Reports Health Investigation Finds Drug Label Warning Inconsistency

July 18, 2011 | Lebowitz & Mzhen

A recent investigation that our Hartford County pharmacy error injury attorneys have been following found evidence that drug labels are often missing the important safety warnings necessary to prevent medication error and that many pharmacies neglect to include the proper medication guides that are required by the U.S. Food and Drug Administration (FDA).

The investigation was performed by Consumer Reports Heath, by filling warfarin prescriptions at five different New York drugstores. Warfarin is a blood thinner used for stroke prevention that is one of the most frequently prescribed drugs in the country.

The results found that four out of the five pharmacies neglected to provide the FDA-approved medication instructions that are required for specific drugs, warfarin included. Although the pharmacies reportedly provided their own medication materials, they were different from the warfarin drug information approved by the FDA, in that the warnings about the usage of alcohol were different. Warfarin can reportedly cause life-threatening internal bleeding if used incorrectly, and is the second in line for drugs that cause emergency room visits in hospitals across the country, due to medication error.

Another goal in the investigation was to see how certain drug labels, consumer drug information sheets, and medication warning stickers differed in each pharmacy. Although a certain degree of variation was expected, as various drugstore chains use different software to print labels and drug instructions, the findings raised significant concern.