Articles Posted in Common Errors

Most Maryland residents find themselves visiting a pharmacy at one point or another. Medications—whether continual or short-term—are a big part of many people’s health and well-being. And ideally, pharmacists and pharmacies help to keep Maryland patients safe and healthy. But sometimes mistakes are made, and these pharmacy errors can cause significant harm to patients. In fact, Maryland pharmacy errors are more common than most people think and can happen to anyone. Recently, however, the Pharmacy Times published an online article about how specialty pharmacists play an important role in increasing patient safety.

Specialty pharmacies, according to the Academy of Managed Care Pharmacy, are distinct from traditional pharmacies and are designed to efficiently deliver medications that have special handling, storage, and distribution requirements. They are also designed to improve outcomes for patients that have complex, potentially chronic and rare conditions. Typically, patients taking specialty medications require more complex services than those required for a traditional drug, and so specialty pharmacists step in to meet those needs.

According to the Pharmacy Times, specialty pharmacists have a unique role in medication safety. Not only do they take responsibility for ensuring the safe and effective use of specialty medications, but they also play a strong role in promoting a positive safety culture within their specific pharmacy. One of the factors pointed towards as causing pharmacy errors is the culture within the pharmacy. Oftentimes, pharmacists are overworked, hurried, and stressed out, and they may sacrifice safety for speed or fail to engage in regular safety precautions. The Pharmacy Times reports that because specialty pharmacists, working with high-risk specialty medications, often incorporate robust programs to ensure proper medication usage and minimize the potential for error, can be really helpful in setting the tone and expectation for safety in typical pharmacy settings. Additionally, specialty pharmacists can encourage the actual reporting of errors within pharmacies when they do happen, which is critical for addressing the root cause of the problem and making sure the same errors do not continue to happen.

Medication errors occur all too frequently in the United States. They account for thousands of deaths each year throughout the country. They may be the result of negligent acts, such as failing to follow proper procedures, failing to communicate necessary information, and failing to verify the patient’s information, including any allergies. In a Maryland medication error case alleging negligence, a medication error victim must prove that the defendant owed the victim a duty by exercising a certain degree of care toward the victim, the defendant failed to meet the requisite standard of care, the victim suffered injuries, and the defendant’s conduct caused the victim’s injuries.

Medication errors can involve the improper administration of a vaccine. According to an analysis conducted by the Institute for Safe Medication Practices of reported vaccine errors in 2017, the majority of errors involved administration of the wrong vaccine. Other errors included expired vaccines, the wrong dose, the wrong age, the wrong timing, the wrong patient, the wrong route, and a component/vaccine omission. In some cases, a vaccine error may simply negate the effect of the vaccine, but other errors may cause injury and even death.

Victims of vaccine errors or other medication errors may be able to recover compensation for their injuries by filing a Maryland negligence claim. Victims often need an expert to testify to prove their case by establishing a link between the medical error and the victim’s injuries. Experts may also be able to testify concerning whether an error was made and who was at fault. Generally, a Maryland negligence claim must be filed within three years of the date of the victim’s injury. Plaintiffs in medication error cases may be entitled to recover financial compensation for medical bills, physical therapy, future medical expenses, loss of earning capacity, lost wages, and other damages.

Each year, medicine and technology get more and more advanced, leading to improvements in the quality and delivery of health care across the country. Despite these improvements, however, errors still occur in health care delivery, particularly regarding pharmacy and medication. In fact, Maryland pharmacy errors occur frequently, jeopardizing the health and well-being of patients. The Institute for Safe Medication Practices (ISMP) is a nonprofit organization that works closely with health care practitioners, institutions, regulatory agencies, professional organizations, and the pharmaceutical industry to create awareness of and provide education about medication errors and how to prevent them.

Every other week, ISMP produces a newsletter with timely information related to pharmacy error prevention. Looking at the newsletters from January 2020 through December 2020 provides important insight into the trends seen in pharmacy errors last year. Pharmacy Practice News recently provided a summary of these newsletters on their website.

In the Pharmacy Practice News summary, several key problem areas were identified. One was safety issues related to labeling, packaging, and nomenclature. For example, a pharmacist might mix-up two different medications that have similar labeling or names, giving the wrong one to the patient. Another area of concern was safety issues associated with order communication and documentation. For example, health officials searching for drugs by generic names and accidentally substituting non-substitutable drugs. Finally, there are problems involving drug information, patient information, patient education, and staff education. For example, two patients mixed up their insulin pens which looked alike but with different labels and manufacturers, meaning they gave themselves the wrong insulin, leading to hyperglycemia.

While the COVID-19 pandemic was understandably the most reported and challenging topic in medicine and healthcare during 2020 (and maybe for 2021, as well), it is important to remember that Maryland pharmacy errors—both COVID-19 related and not—have continued to occur with alarming rates.

Pharmacy errors occur when some mistake is made between the time a prescription is written and the time a patient takes the medication. These errors can come in many different forms. For example, the pharmacist may provide a patient with the wrong medicine or the incorrect dose.

Now that 2020 has come to an end, reflection on the mistakes of the past year is possible. The Institute for Safe Medication Practices (ISMP) recently released a list of the Top 10 medication errors and hazards that occurred in 2020. Factors influencing the list include frequency of problems, the significance of the consequences to patients, and the potential for the errors to be avoided or minimized. ISMP recommends that these ten errors be top priorities in the new year.

In the tragic event of a death after a medication error, the family of a Maryland medication error victim may be able to file a wrongful death claim against those responsible. Maryland’s wrongful death statute generally allows for a claim to be filed by a spouse, parent, or child of the victim. If no spouse, parent, or child exists who may file a wrongful death claim, another person may file who was related to the victim by blood or marriage “who was substantially dependent upon the deceased.” Maryland’s Wrongful Death Act is intended to provide an avenue for family members of the victim to recover compensation for their losses by allowing them to recover for acts that would have entitled the victim to recover compensation if the victim had not died.

In wrongful death claims, the defendant or defendants may blame the victim or argue that the medication error did not cause the death. Just as in Maryland negligence cases, if the victim survives, a wrongful death claim can be barred if the decedent is found to be partially at fault for the error. A defendant may also argue that another medical condition or factor caused the person’s death. The plaintiff has the burden of proving all the elements of the case by a preponderance of the evidence. A wrongful death claim generally must be filed in Maryland within three years of the victim’s death.

Cases Reported of Drug Mix-ups During Spinal Injections

Three cases of accidental spinal injection of tranexamic acid were recently reported on by one news source. The tranexamic acid was reportedly used instead of a local anesthetic because the wrong container was used by accident. In one case, an anesthesiologist used tranexamic acid instead of bupivacaine and recognized the error right away, but the patient had already begun to experience seizures. In another case, the patient again received tranexamic acid instead of bupivacaine and experienced seizures, and was placed into an induced coma for several days. In the last case, the patient received tranexamic acid instead of a local anesthetic but also experienced seizures and extreme pain. Tranexamic acid given in the spine in place of anesthetic can be extremely harmful and has a mortality rate of about 50%. Survivors may experience paraplegia, seizures, ventricular fibrillation, and permanent neurological injury.

Continue reading ›

While Maryland patients often trust their pharmacies to give them the correct prescription medication and dosage, pharmacy errors, unfortunately, do occur consistently throughout the state. These errors can take various forms—such as incorrect dosage or incorrect medication—can be harmless or cause severe injuries and illness. Currently, there are three known pharmacy errors repeatedly happening across the country, reported by the Pharmacy Times. Maryland patients should be on alert for these errors that may affect themselves or their family members.

The first is an error occurring with rapid-acting insulins. According to the Pharmacy Times, errors have been reported due to searching for rapid-acting insulins by generic name, which has caused mix-ups between two insulins that pharmacists may think are the same but are not. The authorized generic version of a new type of insulin has a different onset of action after the injection, and some different ingredients. It cannot be used as an exact substitution for the brand name, although some are prescribing it that way, which may cause issues as patients use it.

The second error is a dispensing error in fentanyl. Transdermal fentanyl patches are placed on the skin. Sometimes, when writing the prescription, there can be multiple confusing numbers that lead to mix-ups. For example, one prescription read “fentanyl patch 72-hour 50 mcg/hour,” with mcg/hour being the dosage or strength of the patch. But the pharmacy employee who entered this prescription into the computer read “fentanyl patch 72,” which led him to mistakenly select a 75 mcg per hour patch instead of 50. This dispensing error can lead to stronger dosages of fentanyl being given to patients.

In this blog, we write about Maryland pharmacy errors, which occur when any mistake is made between the doctor writing the prescription and the patient taking it. Some of these errors include dispensing errors—when a pharmacist makes a mistake dispensing the medication based on the written prescription. These errors can come in a few different forms—maybe the dosage or strength is mistaken, for example—but one of the most dangerous errors is when the wrong medications are dispensed. Usually, we write about instances where this happens on an individual level—when a patient is given the wrong medication—but occasionally, this can happen on a much wider level as well, affecting many patients.

For example, recently, one health clinic experienced a widespread dispensing error thought to have stemmed from a pharmacy machine malfunction. According to a news report covering the story, the wrong medications were mixed in with some prescriptions dispensed between November 9th and 16th at the health clinic. Officials are now reaching out to all those who picked up prescriptions during that time frame to try and make sure they do not accidentally take the wrong medication, which could potentially cause serious injury or illness. But it may be hard to find everyone who picked up prescriptions. For example, officials believe that some individuals had their phone numbers changed since they first entered them into the system—meaning that they cannot find them at the moment.

So far, no serious adverse health outcomes have occurred. But the situation is being monitored closely—it is possible some adverse health outcomes may not be experienced right away. This situation shines a light on how dispensing errors could happen and not be caught. If it’s a new prescription, or one that looks similar to another, individuals might not even realize that there’s a problem and take the medication. If they begin to feel negative symptoms, it may take them a while to figure out that a pharmacy error was the cause, especially since most people expect pharmacists and prescriptions to be accurate.

In this blog, we often write about Maryland pharmacy errors, their potential negative consequences, and how to recover against negligent pharmacies. However, it can sometimes be difficult to understand exactly how Maryland pharmacy errors occur. Today, we focus specifically on dispensing errors—errors that occur as pharmacists dispense medication, which is one of their key responsibilities and a large part of their job.

Dispensing errors are one type of Maryland pharmacy errors that occur when the medication is dispensed into the pill bottle or other package for patients to take home. In this case, the prescription is written correctly by the doctor, but an error occurs when it comes to actually filling it. There are a few ways dispensing errors could occur—a pharmacist could dispense the wrong formulation of a medication, for example, or could put an incorrect label on it. Some research suggests that the most common dispensing errors are prescriptions given with the wrong dosage or strength of the medicine and prescriptions with the wrong medicine altogether.

One of the reasons dispensing errors occur is so simple it might be missed: humans make mistakes. Despite their specialized knowledge and experience, pharmacists are human, and they are prone to mistakes just like everyone else, especially in busy, stressful, and overwhelming work environments. With the current COVID-19 pandemic, unfortunately, these work environments have become the norm, which can exacerbate an already existing problem.

The COVID-19 pandemic has put added pressure and stress and healthcare professionals, especially as some hospitals have seen an influx of hospitalizations due to COVID-19, including the increased risk for medication errors for Maryland patients. A recent report from the Institute for Safe Medication Practices highlights the issue of medication errors related to the pandemic. There has been at least one lethal drug error in a hospital that struggled to cope with a surge in coronavirus cases. According to the report, a nurse who worked at the hospital where the death occurred worked in a busy intensive care unit that was treating about 20 COVID-19 patients each day. The nurse reported that they were overwhelmed with patients and under-resourced, and had stashes of medication left in patients’ closets and drawers. One researcher said a “rushed and hectic environment” can lead to a relaxation of safety measures and double-checks to avoid errors.

The report highlighted the University of Maryland Medical Center in Baltimore, which established a process to review workflow changes and patient safety events at the beginning of the pandemic in order to minimize potential medication errors. The Center made it standard practice to use a single concentration for high-alert medication whenever it was possible. On the other hand, the University of Maryland decided to eliminate a previous requirement that two nurses had to sign off on the administration of all medications. It now allows nurses to administer non-high alert medication without having witnesses present. The Institute provided several suggestions for avoiding prescription errors during the COVID-19 pandemic, including establishing a process for carrying out independent double checks before certain critical infusions are administered and affixing bold auxiliary labels to critical care infusions when dispensing a nonstandard concentration or a neuromuscular blocking agent.

Maryland Medication Error Victims May Be Entitled to Compensation

Maryland pharmacy errors can take many forms—an incorrect dosage, for example, or even the incorrect medicine. Perhaps the pharmacist accidentally prints instructions telling the patient to take the medicine twice a day instead of twice a week, or misreads a doctor’s written prescription. Whatever the error, pharmacy errors have one important thing in common: they are more likely to happen when pharmacists are stressed, overworked, and distracted—three things they have been known to be since the beginning of the COVID-19 pandemic.

With pharmacists and pharmacy technicians overworked and operating in stressful and hectic work environments, it may come as a surprise to many that there has been a significant decrease in the number of pharmacy errors and patient safety incidents being reported since March. According to a Pharmacy Business article, there was a 44.5% decrease in the number of incidents reported during the second quarter of 2020, compared to the first. Additionally, there was a 40.6% decrease in the number of incidents reported compared to the same quarter in 2019. While this may seem like good news, experts say it’s not. In fact, the National Pharmacy Association (NPA) has asked community pharmacies to report all safety incidents—believing that they are currently not doing so. In a recent update, NPA said that the significant reduction in the number of incidents being reported “may be due to the increased workload and pressure on pharmacy teams due to the COVID-19 pandemic, whereby pharmacy teams may not be prioritizing reporting of patient safety incidents.”

It is thus important that Maryland residents understand that a decrease in reported errors probably does not mean an actual decrease in errors—if anything, pharmacy errors are expected to be increasing during this stressful time. Pharmacists are working frantically to fill prescriptions, maintain a safe and clean working environment, and respond to patient requests, with the stress of COVID-19 constantly looming. As such, they are likely to be distracted and hurried, perhaps missing pharmacy errors that could cause significant harm to patients. Maryland residents are encouraged to double-check every prescription and refill to make sure the drug inside the bottle matches the description and the instructions match their doctor’s instructions. If a pharmacy error does occur, they should immediately call their doctor to mitigate any harm. Additionally, in cases causing serious illness or injury, Maryland patients always have the option of filing a personal injury suit against a negligent pharmacy or pharmacist. These suits can help hold the pharmacist responsible and provide monetary compensation for the injured victim, allowing them to pay off their medical bills or cover costs incurred due to the error.

Contact Information