Articles Posted in Common Errors

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.

Modern medicine and technology have expanded the number of drugs and medications available to patients struggling with illness, pain, or other health concerns. However, these medications can be dangerous if taken unnecessarily or in the wrong dosage. Generally, Maryland patients cannot decide which medication they will take—they usually need a prescription from a doctor, who has years of training and experience assessing patients’ needs and prescribing drugs that fit their needs. Maryland residents trust doctors to do this for them, but occasionally errors will be made, or a doctor will have a lapse in judgment, leading to injury to the patient.

For example, recently, a government official reported on a case where a doctor breached his duty of care and acted somewhat negligently, giving a patient access to a potentially dangerous quantity of medication. According to an independent news source, the patient in question had a long history of substance addiction and mental illness. In 2017, she was prescribed two drugs. The prescription stated that the drugs were to be given to her in 14-day supplies, so she only had access to two-weeks’ worth of the drug at a given time.

A few months later, the woman requested a three-month quantity when picking up her prescription. The pharmacy sent the request to her doctor, who changed her prescription to allow the pharmacy to dispense 90-day supplies of the medications without reviewing the patient personally. This, according to the government official’s report, was very dangerous—the type and quantity of the medication could be misused, especially considering the patient’s history of substance addiction and mental illness. The doctor had erred by allowing her a 90-day supply without examining her and considering whether she was at risk for misusing the drugs, and in doing so, increased the risk of harm to the patient.

Every day, many Maryland residents visit doctors for various reasons, ranging from mild illnesses or slight pain to severe sickness or life-threatening medical conditions. No matter the reason, Maryland patients expect that they can trust their doctors to give them high-quality care. Doctors are highly trained and highly educated precisely because of the important nature of their jobs, and so Maryland residents understandably rely on them when something is wrong. But doctors sometimes make mistakes, and unfortunately, sometimes those mistakes can cause severe injury or illness for Maryland patients. One of the most common mistakes doctors make is also one of the hardest for patients to catch before it’s too late—a mistake in the prescription that causes a pharmacy error.

Pharmacy errors can occur at any time between when the prescription is written and when it is taken by the patient. Sometimes the errors are caused by pharmacists filling a correctly written prescription. Other times, however, the doctors themselves make the mistakes while writing out the prescription, usually because they are distracted by something when writing it out. There are several different types of potential mistakes. Doctors may prescribe the wrong drug, for example, or not remember that the drug they are prescribing has adverse side effects when taken with another drug the patient is on. They may also write the wrong dosage, causing a patient to receive either too little or too much of the medication. Doctors may even forget what allergies their patient has and prescribe them a drug that leads to a severe allergic reaction. All of these may occur without a patient even realizing until it’s too late.

If a patient does fall ill or get injured due to a doctor’s negligent error in writing a prescription, Maryland state law allows them to file a personal injury lawsuit. Many people might balk at the idea of suing their doctor, but sometimes it is necessary for a patient to do so to avoid going into financial ruin because of someone else’s mistake. Maryland pharmacy errors can become costly. Depending on the situation, patients can rack up thousands in debt, even hundreds of thousands, due to medical expenses and lost wages. Sometimes pharmacy errors can even be so severe that a patient’s life will be permanently affected. Because the stakes are so high, Maryland law allows patients to hold doctors liable and recover for their losses. The process may seem overwhelming and confusing, but most Maryland pharmacy error victims do not go through it alone—instead, they choose to work with an experienced personal injury attorney who can handle the bulk of the case for them.

Many people will admit that they occasionally get distracted while at work. It’s human nature to get distracted occasionally, and even to occasionally make mistakes. However, in some lines of work, the costs of distractions and mistakes are much higher than others, and employees need to be particularly careful to ensure they are not harming others. This is true, for instance, in pharmacies. Maryland pharmacy errors cause harm and injuries to patients every year. Part of the reason is that pharmacists and pharmacies have recently been expected to handle more and more tasks faster and faster, making it easy for mistakes to occur and not get caught until it is too late.

Recently, an industry news source published a piece discussing the importance of minimizing distractions whilst working in a pharmacy. The post shed light on the fast-paced pharmacy work environment, and how often pharmacists are interrupted while doing important tasks, like filling prescriptions, checking dosages and instructions, and communicating with patients.

According to the post, a recent study found that those working in pharmacies were interrupted an average of seven to thirteen times each hour. The interruptions could be categorized into five major categories: (1) patients walking up to the counter or calling in refills; (2) technicians interrupting pharmacists, usually for assistance on something they are unauthorized to do; (3) pharmacists self-initiated distractions, such as calling a prescriber’s office or initiating a non-work conversation; (4) technological distractions, such as a phone ringing or an announcement over the store’s loudspeaker; and (5) other pharmacists having questions.

Recently, the Pharmacy Times published an article detailing how pharmacy technicians can play a critical role in preventing pharmacy errors. Maryland pharmacy errors can cause serious injuries or illness, leaving those affected with potentially lifelong medical issues. According to the article, the role of pharmacists continues to expand to include more and more duties, meaning that pharmacy technicians are needed more than ever to fill in the gaps. Every year, there are approximately 7 million preventable medication errors. One of the most common errors is incorrect dosing—the Pharmacy Times writes that they make up about 37% of errors each year.

So how can pharmacy technicians help? The technicians are often the first line of defense and best suited to catch errors and prevent them from happening. They are often the ones who type up the prescription, and the ones who take prescriptions from the patient at the counter. They are uniquely situated to prevent pharmacy errors before they happen by double-checking medications.

One experienced pharmacy technician says that all technicians should use a set of “patient rights” while checking medications. Her five steps are designed to help pharmacy technicians systematically check for errors. First, a technician should ensure they have the right patient and ask them to identify themselves. Second, the technician should ensure they have the right medication. Third, the technician should make sure they have the right dose and instructions for how to take the medication. And finally, the technician should confirm the time of the last dose and frequency.

A recent article written by two medical professionals sheds insight into how and when prescription errors occur. According to the article, 7,000 to 9,000 people in the United States die each year as the result of a medication error. In addition, hundreds of thousands of other patients experience an adverse reaction or some other medical complication related to a medication. As we’ve written about before, these pharmacy and prescription errors can cause severe and life-threatening injuries to Maryland patients, so it is essential to be aware of them.

The article discusses the various types of medication errors. While doctors and pharmacists generally do a great job, sometimes errors do occur. A doctor might make an error when prescribing, for example, and may prescribe the wrong drug or the wrong dose. Pharmacists may give the medication to the wrong patient or accidentally tell the patient to take the medicine twice a day instead of twice a week.

These errors have three leading causes, as identified in the article. First, distraction, which accounts for nearly 75 percent of medication errors. Medical professionals are often busy and have many duties in a hospital. While speaking to patients, examining lab results, and ordering imaging studies, for example, they may be asked to quickly write a prescription. In these cases, when the job is done in haste, a medication error may occur—even with the best doctor. Second, distortion. Sometimes a doctor will prescribe a drug but use a symbol not widely recognized, or it will be translated improperly, and the actual drug administered will be slightly off. Last, illegible writing, as simple as it sounds, also leads to medication errors- a pharmacist may be unable to read what the prescription says and may thus use their best judgment and then administer the wrong medication.

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