Articles Posted in Common Errors

Each year pharmacies make millions of medication errors, leading to unintended side effects, and even death. Recent investigations revealed that pharmacies in California alone are responsible for over five million errors annually. Each year, up to 9,000 people die from medication errors, and hundreds of thousands suffer adverse side effects from taking the wrong medication. Pharmacists report that errors are the result of large pharmacy chains pushing quotes and high sales targets while slashing staff and limiting hiring.

Impact on Patients

The impact of medication errors is severe and tangible. Last year, a CVS patient in Ohio received what he thought was ropinirole, a drug used to treat symptoms of Parkinson’s disease. He took approximately 27 tablets of the medication, experiencing severe adverse side effects, including increased anxiety, rapid heart rate, and sweating. It turned out that the bottle contained digoxin, a heart failure drug.

When a doctor prescribes a medication to treat a health condition, patients will often make the effort to use the medication as prescribed. Patients rely on medications to treat their symptoms, and they trust that taking the proper dosage will improve their health. However, when pharmaceutical companies mislabels a medication, they place patients’ health at risk without their knowledge. A patient could follow the instructions on a label perfectly and still suffer injuries due to a mislabeled dosage. In fact, a recent nationwide recall occurred when a pharmaceutical corporation improperly labeled the dosage of each tablet in a medication box.

Recently, a news article reported that Marlex Pharmaceuticals has recalled two improperly labeled lots of medication. The pharmaceutical corporation incorrectly labeled boxes of Digoxin containing 0.25mg tablets as 0.125mg, and incorrectly labeled 0.125mg tablets as containing 0.25mg each. According to the Food and Drug Administration, the mislabeled drugs could cause overdosing or underdosing in patients who believed they were taking the correct dose. Overdosing on Digoxin can lead to significant drug toxicity, including dizziness, memory loss, and fainting. Underdosing can potentially worsen a patient’s heart failure, which Digoxin typically treats.

What Legal Claims Can You Bring After Maryland Drug Mislabeling?

If you have suffered injuries from an improperly labeled drug, your legal claim for damages will likely depend on the cause of the injury. Many lawsuits over mislabeled drugs allege that the label failed to warn the plaintiff of the medication’s potential risks. The manufacturer will often argue that their label adequately warned consumers. However, the plaintiff may be able to argue that the warning label was somehow deficient. For example, a manufacturer may fail to fully warn consumers about the severity or frequency of potential side effects. That is, an incomplete warning can also be a failure to warn.

According to recent reporting by the Los Angeles Times, millions of medication errors occur each year, often at chain pharmacies such as CVS and Walgreens, where a pharmacist may fill hundreds of prescriptions during a shift while juggling other tasks such as giving vaccinations, calling doctors’ offices to confirm prescriptions and working the drive-through. In a recent survey of California licensed pharmacists in 2021, 91% of pharmacists working at chain pharmacies stated that staffing was insufficient to provide adequate care to patients. The state’s Board of Pharmacy, a regulatory board, requires pharmacies to document and track errors internally and inform patients about mistakes under some circumstances, only 62% of pharmacists working in chains stated that stores were following those rules according to the 2021 survey.

The article highlights how medication errors can result in dramatic health issues. One documented error resulted in the improper dose of a hormonal treatment for breast cancer being delivered. Another case resulted in a pregnant patient suffering a fall after she was given two drugs prescribed to another customer. One patient took prednisone, a powerful steroid, for 89 days after a Walgreens pharmacist confused the drug with Prilosec, the heartburn drug that had actually been prescribed. A pharmacist at CVS gave a patient another customer’s prescription for 50-milligram tablets of Zoloft, the antidepressant, according to a February citation. The person took the wrong drug for at least seven months, refilling the prescription three times.

How Common Are Medication Errors?

According to reports, the U.S. Food and Drug Administration (FDA) receives approximately 100,000 medication error reports annually. In 2010, the FDA received only 16,689, but by 2018, the agency was receiving more than 100,000 reports per year. Experts point out that medication error reports are submitted on a voluntary basis, meaning that true medication errors are likely even higher.

When we visit a pharmacy to fill a prescription, we place an enormous amount of trust in the pharmacists and pharmacy technicians. We assume they will provide the correct medication in the appropriate dosage, complete with precise instructions for use. But pharmacy errors happen more frequently than one might think, and the consequences can range from minor discomfort to severe health complications, or even death.

Types of Pharmacy Errors

Wrong Medication: One of the most dangerous types of pharmacy errors is dispensing the wrong medication. With a vast array of medicines that often have similar names, this kind of error can be easily made but is wholly unacceptable.

Unfortunately, incorrect or erroneous distribution or application of medications is surprisingly present in the United States. In fact, some sources cite a rate of one in five Americans experiencing a medical error while receiving health treatment. Unfortunately, Maryland is no exception to this trend, and Maryland residents should be aware of emerging best practices in the face of the increased computerization of pharmacies and hospital medication cabinets.

Additionally, medication errors are among the most common medical errors, harming at least 1.5 million people every year. The extra medical costs of treating drug-related injuries occurring in hospitals alone are at least $3.5 billion a year, and this estimate does not take into account lost wages and productivity or additional healthcare costs, the report says. Medication error morbidity and mortality costs are estimated to run $77 billion dollars per year. Patient safety is a major public health concern.

What Are Medication Errors

According to reports, the U.S. Food and Drug Administration (FDA) receives approximately 100,000 medication error reports annually. In 2010, the FDA received only 16,689, but by 2018, the agency was receiving more than 100,000 reports per year. Experts point out that medication error reports are submitted on a voluntary basis, meaning that true medication errors are likely even higher.

Are Pharmacy Errors Underreported?

Dr. Randall Tackett, a clinical and administrative pharmacy professor at the University of Georgia College of Pharmacy states “What’s reported to the FDA usually only accounts for 1 to 10 percent of what actually occurs.” Dr. Tackett went on to theorize that most medication errors result from the extreme workload that pharmacists are faced with. In an effort to combat this issue, some states have implemented prescription shift limits for pharmacists, limiting them to filling 150 prescriptions per shift. A recent news report describes a pharmacy error.

The Cost of Medication Errors

A recent news report details just how troublesome prescription errors by pharmacies can be, resulting in sanctions. In the state of Iowa, state regulators recently penalized a drugstore accused of destroying relevant paperwork after dispensing the incorrect medication to a customer. According to the Iowa Board of Pharmacy, in 2020 the Walgreen store dispensed the incorrect strength of insulin pens and the incorrect test strips to a patient. During an investigation the Walgreens was unable to provide some of the original documentation related to the prescription. It was determined that the prescription records had been destroyed, which is in violation of Iowa regulations. As a result, the Board of Pharmacy issued a warning and imposed a $1,500 civil penalty, in addition to requiring the store to provide two hours of educational training on patient safety to all permanent pharmacists and technicians on staff. In addition to the one Walgreens being sanctioned, at least one other pharmacy in Iowa was sanctioned for dispensing a prescription with incorrect directions which led to a customer taking a higher dosage than was prescribed. In one case, a pharmacist’s license was placed on probation after a criminal conviction.

How Does Maryland Protect Pharmacy Patients?

Pharmacy boards are administrative agencies created by state governments “to protect the health, welfare, and safety of the public through the regulation of pharmacy practice.” In large part, these entities are responsible for preventing pharmacy errors. State pharmacy boards have taken important steps to regulate and discipline pharmacies and drug laws. For example, in the state of Maryland, the Maryland Board of Pharmacy has a mission of “protect[ing] Maryland consumers and to promote quality healthcare in the field of pharmacy through licensing pharmacists and registering pharmacy technicians, issuing permits to pharmacies and distributors, setting pharmacy practice standards and through developing and enforcing regulations and legislation, resolving complaints, and educating the public.” Guidance by the Office of Inspector General in the United States Department of Health and Human Services outlines that state pharmacy boards should review the outcomes of their disciplinary process and evaluate whether they are affording the public the maximum protection.

While state pharmacy boards play an important role in regulating and disciplining pharmacies and helping protect patients, in some prescription error incidents, victims or the loved ones of victims may consider filing a lawsuit to recover damages. These suits can be complex as you navigate the laws and court system, but connecting with an experienced attorney who can help you navigate your case can be beneficial.

When medication dispensing errors happen, they can cause serious side effects and life-altering issues for patients, and in some cases, these errors can lead to death. According to the National Institute of Health (NIH), each year in the United States, 7,000 to 9,000 people die as a result of a medication error, and hundreds of thousands of other patients experience but often do not report an adverse reaction. Medication errors can cause a lack of trust in the healthcare system generally and in healthcare providers. In addition, these errors have financial costs as well, with the NIH reporting that medication-associated errors exceed $40 billion each year.

According to a recent news report, a medication dispensing error in D.C. almost cost a 74-year-old woman her life. The patient had been recently released from the hospital and went to a rehab facility to recover from a blood clot. However, within weeks, the patient began complaining about swelling in her throat, prompting her family to look at what prescriptions the facility had given her. Her family members realized that the facility had dispensed the wrong medication, giving her drugs with someone else’s name on them. To make matters worse, the patient’s eldest daughter realized that the facility had given her a drug that her mother was severely allergic to. The patient was raced to the nearest emergency room just in time, as her throat was nearly swollen shut. She was put into a medically induced coma for more than a week.

Why Do Medication Dispensing Errors Happen?

Medication dispensing errors can occur for a variety of reasons, including human errors or issues with protocols that fail to prevent mistakes from happening. These reasons may include illegible handwriting, confusion over similarly named drugs or packaging, or errors involving dosing units, amongst many other reasons. In addition, if protocols and systems are not properly and effectively put in place to require that medical providers have a backup system to detect mistakes, then this can also lead to more pharmacy errors that could have possibly been avoided.

Medication error has been a leading cause of harm for patients, and an expensive cost for healthcare providers. In a digital age, some healthcare providers have implemented digital solutions to medication errors, but these digital solutions can cause doctors to receive too many alerts that lack specificity and that also cause alert fatigue for doctors. However, when science and technology combine to create a unified and efficient approach for drug administration and managing clinical decisions, it can be life-altering. A Healthcare IT News article details the importance of hospitals integrating precision medicine with digital maturity models. The digital maturity models can help technology advances that support clinical decisions. This can help prevent errors and increase efficiency, which thus can save lives and costs for hospitals. Giving users access to a single information source in a unified approach can help with drug administration and minimize alerts.

What Is a Digital Maturity Model?

Some examples of digital maturity models include from Wolters Kluwer, which built Medi-Span Clinical APIs drug data solution and expert services which helps ensure that accurate information is available at key moments rather than reported after the event, and also ensures the precision of alerts. Another example is the National Chen Kung University Hospital in Taiwan, which has used Medi-Span Clinical APIs to overcome challenges faced by pharmacists, including the challenge of the amount of time it takes to update a medication database. Medi-Span’s databases are updated regularly with best practice evidence and recommendations. Clinical APIs are for healthcare professionals only, and there are certain regulations that guide their use in various locations.

The hospital’s data shows that since implementing Medi-Span, the number of alerts has been reduced by 21% and the talerts have captured severe potential Adverse Drug Events. This resulted in saving approximately $39,200 in U.S. dollars a year, and also saved an estimated 266 bed days a year. Technology advances can allow for solutions that help prevent medication errors and help ensure that patients receive the best and safest care possible. When these errors occur but can be avoided by digital maturity, it is up to hospitals to implement unified approaches to avoid such costs.

When it comes to our prescriptions, we count on pharmacies to get it right. Instructions scribbled by doctors on notepads or hurriedly said by nurses and office staff while we check our calendars for follow up appointments or scrutinize our bills are hardly reliable. Instead, checking and double-checking pill bottles or printed pharmacy instructions before consuming prescription medication is often the safeguard patients use to ensure they’re not over or under consuming their prescribed drugs. When these instructions are wrong, the results can be catastrophic.

What Are the Potential Harms of a Medicine Dosing Error?

According to a recent report, a prescription for alirocumab, a drug to prevent cardiovascular events, was marked with erroneous directions. The pharmacy instructed the patient to inject “1 mg,” or one milligram, under the skin every 2 weeks. But the actual instructions were supposed to be injection of one milliliter. The instructed dosage would have been confusing and impossible to measure for a patient. While this error was fortunately realized by the patient due to the difficulty in measuring one milligram, other such errors—like transcribing a number incorrectly—could result in over or under-consumption of medications, which can lead to overdose or prolonged illness.

In this case, the error occurred because the verification by two pharmacists failed to catch the mistake. Some pharmacies do not have processes for typing directions, even though these medications should often be administered in a standardized way. Doctors provide varying instructions, and pharmacies often follow the doctors’ instructions verbatim or close to it, without verifying the units and dosage against standards for the medication. The prescription in question would have also been easier to understand had the pharmacist instructed the patient to inject one entire pen, rather than 1 milliliter or milligram, as the pen was designed to hold one dose. Pharmacies can also employ more checks to ensure patients understand how to use medications, like asking patients to repeat instructions back and confirm dosage.

Contact Information