Articles Posted in Common Errors

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.

When people experience medical issues, they will, understandably, rely on healthcare professionals to provide them with appropriate treatment. Individuals should expect that their medical providers quickly and accurately diagnose them and prescribe the correct treatment and medication. When someone suffers injuries after taking the wrong medication or dosage, the provider or pharmacist may be liable under Maryland’s medical malpractice laws. Although mistakes can happen, medical providers have a duty to provide their patients with necessary and appropriate medical care. The failure to provide a patient with correct medication can lead to serious and life-threatening illnesses.

About 20 years ago, the Institute of Medicine released its “To Err is Human” report, highlighting the importance of building a safer health system. However, medication errors continue to be a serious risk for patients throughout Maryland and the United States. As the report suggests, pharmacists play a critical role during the prescribing, dispensing, and administration of medication, and they must take steps to prevent medication errors. A recent news report summarizes some of the most crucial steps pharmacies can take to reduce the likelihood of a Maryland pharmacy:

Organize the pharmacy: The inherent fast-paced and intense nature of pharmacies can result in disorganized and chaotic work spaces. Pharmacists should have a system in place to ensure that patients’ prescriptions and medications do not become lost or misidentified. The Institute for Safe Medication Practices (ISMP) advises that pharmacies use consistent systems, such as bins or baskets, to separate different patients’ prescriptions and medications.

Medical errors are estimated to the third leading cause of death in the United States. Even when they are not fatal, these errors often have a profound impact on a patient’s life. While there are many different types of medical mistakes, Maryland pharmacy errors can be among the most devastating, especially for the elderly and young children.

While there is a risk of error any time a pharmacist fills a prescription, certain situations present an increased risk. For example, according to a recent news report, the following are a few of the most common medication errors.

Zinc overdoses: Zinc is a mineral that most people consume every day in their diet. Small doses of zinc are beneficial and may help fight colds. However, it is possible to overdose on zinc. In fact, in 2019, a two-year-old was almost given a fatal dose of zinc that was 1,000 times more potent than necessary when a physician prescribed 700 milligrams instead of 700 micrograms.

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Pharmacists at the country’s biggest retail chains have written letters to state regulatory boards in recent months alerting them to what they claim are chaotic workplaces that put patients at risk, according to a recent article. The pharmacists say that the pressures put on them require that they give shots, answer phones, mange drive-throughs, take payments, and make calls in addition to filling prescriptions and counseling patients. They say that these demands in addition to meeting corporate metrics are making their jobs unsafe for patients. According to the article, surveys of pharmacists in Maryland and other states reveal that they “feel pressured or intimidated to meet standards or metrics that may interfere with safe patient care.”

For example, internal documents from CVS showed that staff members were supposed to persuade 65 percent of patients that were picking up prescriptions to sign up for automatic refills, 75 percent to have their doctor contacted for a proactive refill request, and 55 percent to switch from a 30-day supply to a 90-day supply.

One pharmacist wrote that they were  a “danger to the public” in a letter to the Texas State Board of Pharmacy. Another said the situation is “absolutely dangerous” to patients. Such pressures have led to mistakes they say, including misfills. Some mistakes have led to devastating results, including dispensing a cancer drug instead of an antidepressant, leading to the woman’s death after six days of taking the medication, which allegedly led to organ failure. The family was offered a settlement in that case.

The Institute for Safe Medication Practices (ISMP) is warning pharmacists and medical practitioners about the potentially severe consequences of using abbreviations for drug names. Their recent report, submitted to the National Medication Errors Reporting Program, sheds crucial light onto one way in which patients could be injured by a Maryland pharmacy error—through miscommunications and mix-ups based on drug abbreviations.

For example, according to an article discussing the ISMP’s report, one commonly confusing abbreviation is “tPA,” which refers to “tissue plasminogen activator alteplase (Activase).” In one situation, an urgent order for alteplase for a patient in an intensive care unit (ICU) was sent to the pharmacy. A nurse from the ICU called the pharmacy to ask if the “tPA” was ready, but the pharmacist, who was newly hired and unfamiliar with the abbreviation tPA, thought the request was for “TPN,” or “total parenteral nutrition.” The pharmacist then told the nurse that the drug would be there in a few minutes, since they were currently mixing parenteral nutrition solutions.

Later that day, when the needed alteplase did not arrive, the ICU nurse called the pharmacy again. Another pharmacist answered, saw the urgent order in the database, and began to dispense a dosage of the drug. Unfortunately, in her rush, she forgot to mix the drug according to the protocol for inpatient use and was delayed while re-dispensing and mixing the drug. This delay, since the drug was already delayed due to the abbreviation mix-up earlier, led to the hospital calling a rapid response team for the patient in question.

When a pharmacist incorrectly fills a patient’s prescription, the pharmacist may be liable to the patient for any injuries that occur as a result of the medical error. However, in a Maryland pharmacy error lawsuit, a patient must be able to prove not just that an error was made, but that the pharmacist’s error caused them harm. While this may sound simple in theory, in practice the issues of causation and damages often raise significant hurdles.

Take, for example, a recent pharmacy error. According to a recent article, a patient was given a prescription for “Potassium Citrate ER 10 MEQ (1080mg) CR-TABS” after having a procedure to remove several kidney stones. The hospital printed out the correct prescription, and the patient took the prescription to be filled at a satellite location of the hospital pharmacy. However, upon taking it to the pharmacy, the patient was provided with “Potassium CL 10 MEQ 120.”

According to the man’s claim, the hospital’s pharmacy later called a local Rite-Aid to transfer the prescription, at his request. However, rather than calling in the correct prescription, the hospital pharmacy called in the Potassium CL 10 MEQ 120 pills. The man continued to take the medication for seven months, refilling the prescription each month. In total, the patient took the wrong medication for 10 months. During this time, the patient continued to form kidney stones, requiring additional treatment.

When a patient takes a prescription to the pharmacy to get it filled, they assume that the medication they are picking up is the one prescribed by their physician. However, that is not always the case. Indeed, each year, there are thousands of Maryland pharmacy errors, many of which result in severe injury or death.

Patients should be vigilant when it comes to double-checking all prescription medication for themselves, as well as for their loved ones. Pharmacy errors can occur in many ways; below is a partial list of some of the more common types of pharmacy errors.

Giving the patient the wrong medication: Perhaps the most common type of pharmacy error is when a pharmacist provides the patient with the wrong medication. These errors are very dangerous because the patient ends up taking a drug that they were not prescribed in an unknown dose. Additionally, the patient is not receiving the medication that they were prescribed, potentially worsening any existing condition.

The issuance and administration of medication can seem routine, but those procedures result in millions of errors, many of which are preventable. In the case of a medication error, a victim may be able to recover compensation if they are able to prove that the provider was negligent and that they suffered harm as a result.

In a medical negligence claim, plaintiff has to show that a defendant healthcare professional owed the plaintiff a duty of care, that the healthcare professional failed to meet the standard of care in acting or failing to act in some way, that the plaintiff was injured because of that failure, and that the healthcare professional’s lack of care caused the plaintiff injuries. Medication error cases can be difficult to prove, particularly because the patient is often already sick and suffering from some disease or condition to begin with. Reliable expert testimony is often crucial in these cases.

Plaintiffs in medication error cases may be able to recover compensation for medical expenses, physical therapy expenses, lost wages, loss of earning capacity, and other damages.

Medical mistakes, including pharmacy errors, are among the leading causes of death in the state. Notwithstanding the data showing that preventable medication errors affect nearly 7 million patients per year, most people maintain an “it could never happen to me” approach when thinking about these potentially dangerous errors. However, the reality is that anyone can fall victim to a Maryland pharmacy error.

Not all pharmacy errors are harmful, and fewer yet are fatal. In fact, most pharmacy errors are caught by another pharmacist or the patient. Of the patients who end up bringing the incorrect prescription home and taking it, few will experience immediate side effects. That, however, does not mean that the un-prescribed medication will not cause the patient harm; only that there are no immediate effects.

The best way to avoid suffering the ill effects of a Maryland pharmacy error is to prevent the mistake from happening in the first place. Of course, the duty to prevent a mistake does not ultimately rest with the patient; however, patients should still double-check all prescriptions and seek a consultation with a pharmacist when taking new prescriptions.

Included among the responsibilities of a Maryland pharmacist is the duty to ensure that the medication provided to a patient does not negatively interact with the patient’s other prescriptions. Prescription medications contain powerful drugs and many prescription medications should not be taken with other prescription medication or even over-the-counter medications.

There are several types of drug interactions, including pharmacodynamic and pharmacokinetic interactions. A pharmacodynamic interaction occurs when two medications that react with the same receptor site are taken at the same time. Pharmacodynamic interactions result in the ingested medications having a greater (synergistic) or decreased (antagonistic) effect, depending on the specific medications involved. Pharmacodynamic interactions can be fatal.

Pharmacokinetic interactions occur when one drug affects the body’s ability to absorb, metabolize, distribute, or eliminate another medication. For example, calcium can bind to some medications, reducing their absorption. Thus, patients are advised not to take the HIV medication Tivicay at the same time as Tums because the calcium in Tums can lower the amount Tivicay that is absorbed into the patient’s system. In this situation, doctors suggest patients take the two medications at staggered times throughout the day.

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