Common Errors

Three Common Causes of Prescription Errors in Maryland and Nationwide

September 24, 2018 | Lebowitz & Mzhen

The increasing number of Maryland pharmacy errors has drawn attention not just from within the industry but also more broadly from the media and lawmakers. As the population grows and pharmacies take on more patients, the number of prescriptions filled per day continues to grow exponentially. With limited space and the pressure to keep costs down, pharmacies often have a difficult time staffing enough pharmacists and technicians to safely fill patients’ prescriptions.

This is not to say that being busy is an excuse to commit an error. It isn’t. In fact, regardless of how busy a pharmacist is, how long they have been on a shift, or how many prescriptions they have filled in any given day, pharmacists always have a duty to ensure that the prescriptions they fill are accurate.

A recent industry news source discusses several common errors that are seen in pharmacies across the country. As is the case with most errors, these are based on a lack of communication, problems with data management, and issues with conveying important and technical information quickly.

Pharmacy Errors on the Rise, According to One Industry Source

August 27, 2018 | Lebowitz & Mzhen

Medical errors routinely rate among of the most frequent causes of preventable death in the United States. One of the more common types of medical errors are pharmacy misfills or prescription errors. These errors occur when a pharmacist provides a patient with the wrong medication, wrong dose, or wrong instructions.

According to one industry news source, pharmacy errors are on the rise. Evidently, the National Pharmacy Association released its most recent data which showed a 64% increase in pharmacy errors between April and June of this year. The data showed that nearly half of all of the reported pharmacy errors were caused by “workload and time pressures.”

The types of errors reported varied, but the following were some of the more common error types:

providing the wrong medication to the patient based on medication with similar sounding or looking names;
mixing up patients’ names and addresses; and
attaching the wrong information slip to a patient’s prescription.

Decreasing Errors Involving Look-Alike Sound-Alike Drugs

August 21, 2018 | Lebowitz & Mzhen

While there are many causes of Maryland pharmacy errors, one of the most frequently reported errors involves a patient receiving the wrong medication from their pharmacist. In many cases, the pharmacist provides a patient with a drug that has a name similar to the drug which they were prescribed.

The Institute for Safe Medication Practices (ISMP) has coined the term look-alike sound-alike (LASA) drug to describe a medication that is either spelled or pronounced similar to other medications. It is estimated that up to 35% of all medication errors involve LASA medications. The IMSP has also published a list of the most common LASA drugs.

For example, common LASA drugs include:

hydromorphone and morphine
vinblastine and vincristine
tramadol and trazodone

Institute for Safe Medication Practices Discusses Common Pharmacy Errors in Recent Presentation

June 22, 2018 | Lebowitz & Mzhen

Each year, it is estimated that there are approximately 700,000 medication errors resulting in over 100,000 patient hospitalizations. The pharmacy industry realizes that this is a major problem, and for decades has been taking steps to reduce the rate of prescription errors among retail and hospital pharmacists. Most recently, a representative from the Institute for Safe Medication Practices (ISMP) gave a lecture discussing common types of pharmacy errors and what pharmacists can and should do to guard against them.

Medication errors occur due to a breakdown somewhere along the line; from when a physician writes a prescription to when the pharmacist provides it to the patient. According to a recent industry news report detailing the speaker’s comments, she claimed that pharmacy errors occur throughout various points in the process, and pharmacists should take precautions every step of the way.

The ISMP representative discussed that there are several situations in which an error was more likely to occur. For example, when a pharmacist is dealing with drug shortages, vaccines, improperly or unlabeled medication, and insufficient drug allergy alerts, the rate of error was highest. The pharmacist detailed three of the most alarming prescription errors that she was made aware of over the past year, including:

A patient who was prescribed 25 mg of hydralazine rather than the prescribed medication, hydroxyzine;
A child-patient who developed Parkinson-like symptoms after being provided with an improperly diluted dose of risperidone; and
An elderly Alzheimer’s patient who was given both a 5mg and 10 mg dose of donepezil at the same time rather than the prescribed 5mg dose for four weeks to be followed by the 10mg dose afterward.

Maryland Pharmacy Errors and Steps to Protect Against Medication Errors

May 22, 2018 | Lebowitz & Mzhen

While the exact number of Maryland pharmacy errors is disputed, the U.S. Food and Drug Administration offers a conservative estimate of approximately 7,000 deaths per year due to medication errors. Due to lenient reporting requirements in the pharmacy industry and the industry’s interest in keeping errors out of the mainstream news, experts believe that the true number of errors is much higher. Some reports suggest that upwards of 1.3 million people are harmed each year by prescription errors.

Prescription errors have a number of potential causes. However, like most mistakes, the most common cause is that the pharmacist filling the prescription overlooked something they shouldn’t have. Poor communication between health care professionals plays a role in many pharmacy errors. Along those lines, pharmacists will often misinterpret a physician’s abbreviations, either prescribing the wrong medication or the wrong dose. Mistakes are also commonly made involving drugs with similar-sounding names.

Each of these situations involves one common variable: a negligent pharmacist. Undoubtedly, most of the pharmacists who are responsible for pharmacy errors are well-intentioned. However, given the everyday stress and steady workload, many pharmacists end up taking short cuts that can hurt their patients.

New Report Indicates Prescription Errors May Claim over 100,000 Lives Annually

May 15, 2018 | Lebowitz & Mzhen

The chances are that anyone who has dropped off a prescription or refill request to a retail pharmacy has had to wait a considerable amount of time for the pharmacist to fill the prescription. First, the patient must wait in line to drop off the prescription. Then, the pharmacist often tells a patient to come back in at least 30 minutes – sometimes even longer.

While waiting 30 or 45 minutes for a prescription to be filled isn’t a problem for most patients, the fact that a pharmacy is so busy raises some concerns for pharmacy experts. According to a recent news report discussing the prevalence of errors and what can be done to curb them in the future, it is estimated that there are approximately 100,000 deaths caused by pharmacy errors each year. The leading cause of Maryland pharmacy errors is commonly understood to be an overworked pharmacist.

The article details the startling account of a woman who was provided the wrong medication by her local pharmacy. The woman was prescribed the pain medication Gabapentin. Her physician instructed the woman to take the medication three times a day, taking two pills for each dose.

Children May Be at Increased Risk for Prescription Errors

May 8, 2018 | Lebowitz & Mzhen

Prescription errors can have devastating consequences for people of any age. The wrong dosage or medication can have long-lasting consequences and, in some cases, can be fatal. A recent article shows how children may be at greater risk for prescription errors in some circumstances. Since some medication is produced at dosages that are too high for children, they have to be reduced. The process of creating a smaller dosage is another opportunity for prescribers and pharmacists to make mistakes and for miscommunications to occur.

In the case of a Maryland prescription error, a plaintiff must demonstrate that the defendant was negligent by failing to meet the relevant standard of care. An example of this might be a pharmacist’s failure to administer the prescribed dosage. In these cases, a plaintiff may be entitled to compensation for their injuries.

Article Reveals Life-Threatening Errors in Administration of Flecainide to Children

Flecainide, an oral antiarrythmic drug, can be prescribed to treat supraventricular tachycardia or atrial fibrillation. However, it is only available commercially in doses of 50 mg, 100 mg, and 150 mg, so when given to infants and small children, who require smaller doses, it has to be given in the form of a suspension. A recent article discusses how there have been life-threatening errors during the preparation of the suspension, resulting in serious overdoses.

The Dangers of Pharmacy Errors Involving Opioid Medications

March 11, 2018 | Lebowitz & Mzhen

Over the past decade, the U.S. has seen a dramatic increase in the number of deaths as a result of opioid use and abuse. Indeed, according to the most recent government statistics, over 35,000 people die each year as a result of opioid overdoses. Roughly half of these deaths are caused by prescription painkillers. These figures represent a nearly three-times increase over previous years.

The recent rash of opioid deaths has called into question the medical profession’s reliance on these drugs to treat pain. Notwithstanding the well-understood dangers of opioid use and abuse, opioid painkillers are still prescribed in record numbers each year. Not surprisingly, given the number of prescriptions filled each year, there are a significant number of pharmacy errors involving opioids.

Regardless of the type of medication involved, pharmacists have a duty to ensure that a patient’s prescription is filled accurately. This means not only making sure that the correct drug is provided to the patient, but also providing the proper dose and instructions. When pharmacists make an error involving a drug as dangerous as an opioid painkiller, there is a high likelihood that the patient could accidentally overdose.

As Online Retailer Enters Pharmaceutical Business, Some Are Advocating for Change

December 1, 2017 | Lebowitz & Mzhen

The online retail giant Amazon recently announced that it would soon be entering the pharmacy business. With Amazon’s impressive delivery network, the company believes that it has a service to offer those who would otherwise need to travel to the nearest pharmacy to fill their prescription. Some believe that Amazon’s entrance into the pharmacy business may reduce the number of Maryland prescription errors.

Due to the volume of transactions that Amazon handles annually, some are seeing Amazon’s entrance into the pharmacy business as an opportunity for the industry to make major strides toward a safer process. The idea is that Amazon has the clout necessary to make pharmaceutical companies make changes to the way drugs are packaged and marketed.

According to a recent industry news report, the leading cause of pharmacy errors is inadvertence. Simply stated, most pharmacy errors are results of a busy pharmacist grabbing the wrong medication because its name or packaging is so similar to the medication the patient requires. And, according to the article, drug manufacturers have little reason to change because they are not normally held liable for errors. However, the article notes that as Amazon enters the business, the company may be able to use its influence to require manufacturers to make changes to the way companies package and market their drugs, potentially resulting in an overall decrease in the amount of pharmacy errors.

Pharmacist Trainees Admit to Frequently Making Errors

November 22, 2017 | Lebowitz & Mzhen

As is the case with most professions, becoming a pharmacist involves not only getting an education but also obtaining the necessary hands-on experience. Of course, as medical professionals, pharmacists are responsible for the safety of their patients, and any Maryland pharmacy error made by a trainee can have potentially drastic consequences for a patient’s health. Thus, normally, pharmacists in training are closely supervised to ensure that any mistakes they make are caught and fixed before the prescription is passed on to the patient. However, providing this level of supervision is costly to pharmacists, and too often efficiency is favored over safety.

In a recent article discussing the high frequency of pharmacy errors and potential ways to cut back on the number of errors, it was suggested that pharmacists may make fewer mistakes once they are certified to work on their own if they are allowed to make mistakes in training. The proposition is not a surprising one, since it has often been said that “practice makes perfect.” However, in the context of the medical field, patients rightfully expect “perfect” performance when it comes to filling their prescriptions.

The article discusses one pharmacist’s experiences in training and proposes a method to ensure that pharmacists in training are able to make the mistakes they need to make and learn from them. For example, the pharmacist explained that he would have to fill 1,000 prescriptions in a row without an error before he could move on to his next exercise. If he made a single error anywhere along the way, he would start back at zero. He explained the frustrating in reaching 200 prescriptions several times, only to make a minor error.