Common Errors

Alert Fatigue Shown To Be a Major Factor in Many Pharmacy Errors, Solutions May Be Coming

June 15, 2015 | Lebowitz & Mzhen

Whenever a pharmacist is filling a prescription, if there is the potential that the medication they are providing to a patient may have an adverse interaction with another medication, should be taken with specific instructions, or is otherwise potentially dangerous, an alert will pop up on the pharmacist’s screen. However, given that most medications are dangerous under some circumstances, and pharmacists can fill hundreds of prescriptions a day, theses alerts tend to bog a busy pharmacist down.

What is Alert Fatigue?

According to a recent industry report, alert fatigue occurs when a pharmacist is so accustomed to seeing an alert pop up that they almost automatically disregard the alert as unimportant. Reasons for dismissing the error vary, but the end result is the same. The patient ends up taking the prescription home and consuming it, leading to a potentially disastrous situation. As one can imagine, alert fatigue is the cause of a substantial number of pharmacy errors, since pharmacists are substituting their own on-the-fly judgment for the tried and true research of medical professionals.

What Can Be Done About Alert Fatigue?

Given that alert fatigue is a real problem in pharmacies across the United States, there has been a concerted effort by some in the industry to address the issue. One potential solution, according to the article discussed above, is the implementation of software that provides more accurate, more specific, and more targeted alerts. These new programs may also provide a “threat-level” for the pharmacists, so they are able to tell how serious an alert really is.

Five Dangerous Drug Combinations That Can Cause More Harm Than Good

June 1, 2015 | Lebowitz & Mzhen

Over-the-counter and prescription medications are used by almost everyone to treat medical conditions from time to time. Often, these medications are powerful drugs that if used properly can have miraculous effects, curing or minimizing the symptoms or causes of a disease. However, they can also do great harm if abused or if taken with other medications.

A recent study by the Center for Disease Control claimed that 28% of adults have two or more prescriptions during any given month. These prescription drugs—and even over-the-counter medications—can have nasty effects if taken together. Earlier last month, an online news source posted an article about some of the most dangerous, yet common, prescription and over-the-counter drug combinations that can result in serious negative long-term effects.

Drug Combinations To Avoid

The following is a list of medication combinations that should be avoided:

Confusion on Prescription Drug Label Leads to Pharmacy Mix-Ups

May 26, 2015 | Lebowitz & Mzhen

Earlier this month, the FDA issued a prescription-drug watch surrounding the anti-bacterial drug, Zerbaxa. According to a recent report by Pharmacy Practice News, the FDA’s warning was based around the fact that the dosing information on the label of Zerbaxa cartons was confusing and not uniform with other prescription drugs, leading to the possibility of a pharmacist providing a patient with an incorrect dose of the medication. The report has caused the manufacturer of the drug to alter the drug’s label to make it more accurate and more easily read.

Evidently, Zerbaxa consists of two active ingredients, both of which are listed on the front of the drug’s carton. However, on the old label, the two active ingredients were listed separately, one after another. For example, on a package that contains a total of 1.5g medicine, the label read: 1g/.5g. This could give a pharmacist the idea that the amount of medicine in the carton was 1g and that it was equal parts of each active ingredient.

In fact, according to the FDA, there have been several pharmacy errors made involving this exact situation, seven since the drug’s approval back in December 2014. In four of these cases, the patient took the extra dose and suffered an injury. Thankfully, they suffered no serious harm as a result. In the three other cases, someone caught the error before the patient actually took the medication.

Walgreen’s Pharmacy Error Nearly Resulted in Fatal Overdose

March 23, 2015 | Lebowitz & Mzhen

Earlier this month in Orlando, Florida, a woman collapsed and was admitted to the hospital after she was given a dose of medication by her pharmacist that was ten-times stronger than prescribed by her doctor. According to a recent report by one local Florida news source, the woman was filling her blood-pressure medication at a local Walgreen’s when she was provided with the wrong pills.

The woman had been taking the medication for a number of years and recalls noticing that the pills were a little larger than her normal prescription, but told reporters that she figured she had just been provided with a generic form of the drug. However, after she took just one pill she collapsed as she approached her bed; luckily it padded her fall.

Evidently, the pills that the pharmacist provided her were ten-times stronger than what her doctor had prescribed; rather than being 10mg, the pills were 100mg. The pills were the same shape, slightly larger, and had the same markings as her normal pills. When confronted about the error, the pharmacist told the woman’s husband that the 10mg pills were on the same shelf right next to the 100mg pills.

Use of “Performance Metrics” May Increase Total Number of Pharmacy Errors

March 16, 2015 | Lebowitz & Mzhen

Pharmacies are businesses. And, like all businesses, the number one goal of a pharmacy is to remain profitable. Of course, most pharmacists are good people and truly care about their patients. However, the pharmacists are rarely the ones making the staffing policies that can lead to pharmacy errors.

It has been argued by some sources that many, if not most, of the prescription errors that occur today are caused by overworked pharmacists. An understaffed pharmacy is much more likely to send out a prescription with an unprescribed medication, an incorrect dose, or a wrong number of pills.

This trade-off between the profit and safety has caused some concern over the past few years in the field. However, one new trend that is appearing in pharmacies across the country threatens to worsen the already imperfect system by applying another set of pressures on already overworked pharmacists.

Pharmacists Told To Keep Similarly Named Medications Away from Each Other

October 2, 2014 | Lebowitz & Mzhen

Pharmacists are charged with a very important duty in our society: to verify and fill prescriptions issued by physicians and to answer any patient questions that may arise. In addition, pharmacists are a second line of defense against physician error, checking prescriptions against other medications that the patient is taking.

However, with the burden on pharmacists increasing as more and more people obtain healthcare, it seems that corners are being cut, potentially increasing the risk of a pharmacy error.

In fact, one report recently released by Pharmaceutical Journal discusses a recommendation that pharmacists keep similarly named medications physically apart from one another to reduce the chance of confusion.

New Study Finds that Two-Thirds of Pharmacists Miss at Least 20% of Dispensing Errors

September 15, 2014 | Lebowitz & Mzhen

According to a study that was recently conducted in the United Kingdom, pharmacists miss errors in prescriptions in a frightening number of cases. According to a report by the Pharmaceutical Journal, the study results were unveiled at the Royal Pharmaceutical Society Annual Conference earlier this month.

The study took 103 local pharmacists and had them fill 50 prescriptions in 25 minutes, which is generally considered a normal, if slightly heavy, workload for that amount of time. Five of the 50 prescriptions intentionally contained errors. There were also a few distractions that were thrown at the pharmacists while they were filling the test prescriptions, but nothing out of the ordinary for the profession.

The idea of the study was to see how many of the pharmacists would catch all five of the errors. The results were frightening. Below is a summary of the results:

Confusing Drug Names May Lead to More Prescription Drug Errors

August 20, 2014 | Lebowitz & Mzhen

Prescription drug injuries are becoming more and more common as pharmacies try to meet the increasing demands of their customers without hiring additional staff members. While there are several potential causes for a pharmacy misfill, one recent article points out that the similarity of different drug names may play a role in the confusion, increasing the chances of an error.

Confusion Can Lead to Serious Injury or Even Death

Although some medication errors can cause little or no harm to the patient taking the drug, others can cause permanent or serious injury or even death. Suppose that the prescription is for a life-threatening condition that, if the patient does not get his or her medication, he or she could die. If a pharmacist fills that patient’s prescription with the wrong drug—even if the improperly prescribed drug was harmless—the patient may suffer serious injury or death.

Dosage confusion is also an area that can result in serious injury. If a doctor improperly prescribes a larger-than-needed dose, and the patient takes the prescribed dose, he or she may be at risk of an overdose. The same is true for an under-dose.

Study of “Collaborative Pharmaceutical Care” Finds 3/4 Reduction in Hospital Medication Errors

March 19, 2014 | Lebowitz & Mzhen

A new study, conducted in Irish hospitals and published in a British journal, reviewed the effectiveness of a “collaborative” model of managing hospital patients’ medications. The model, known as the Collaborative Pharmaceutical Care in Tallaght Hospital (PACT), involves close involvement of clinical pharmacists in all stages of patient care during their stay in the hospital. The study, which was uncontrolled, found that PACT resulted in a reduction in the rate of medication errors by more than three-fourths.

The study was published in the online edition of the British Medical Journal Quality & Safety on February 6, 2014. The researchers compared the benefits of PACT to “standard ward-based clinical pharmacy,” with a focus on adult hospital patients receiving acute care, who were prescribed at least three medications in the hospital, and who left the hospital alive. The study included 112 patients receiving care based on PACT, and 121 patients receiving standard care. They measured the rates of medication errors and of potentially severe errors per patient.

According to the description provided in the study, the primary goal of PACT is to reduce the rate of medication errors that commonly occur when a patient is transferred between doctors or departments within a hospital, or transferred from one facility or organization to another, by improving the process of “medication reconciliation” (MedRec). This involves comparing a patient’s current medication orders to the medications a patient has been taking in order to prevent omission of a necessary drug, inclusion of an unnecessary or dangerous drug, or incorrect dosages.

Washington DC News Investigation Finds Multiple Medication Errors at National Pharmacy Chain

February 27, 2014 | Lebowitz & Mzhen

In a report on its investigation of the national pharmacy chain CVS/pharmacy, Washington DC’s NBC affiliate, News 4, claims to have found numerous alleged medication errors and other problems. Consumers reported receiving the wrong prescription and, in at least one case, meeting with indifference from employees. A former CVS pharmacist with more than thirty years at the company filed a whistleblower lawsuit last year, alleging in part that the company fired him in retaliation for reporting his concerns about an increasing rate of medication errors due to staff reductions. CVS has denied the allegations against it and publicly stated its commitment to protecting patients’ health and safety.

Washington’s News 4 reported a woman’s claim that CVS made a mistake when refilling her prescription for potassium citrate, which she took for her kidneys. She noticed that the pills did not look familiar, and saw that the pharmacy had given her a bottle of potassium chloride instead of citrate. The pills look similar and have similar names, but they have very different uses. Potassium chloride is used to treat hypokalemia, or low blood potassium, and can cause serious, even fatal, complications for some kidney patients. The woman claimed that when she notified the pharmacy manager of the mistake, he responded “Well, potassium is potassium.”
The report also looked at automatic refills, a service offered by CVS and other pharmacies. This allows the pharmacy to refill a prescription at regular intervals, so that the patient does not have to call and request a refill. Problems may occur, however, if the pharmacy refills prescriptions that the patient does not want or need. An elderly patient told the news team that he ended up with more Lidoderm patches, which contain an extremely strong painkiller, than he wanted, based on the auto refill system. This could lead to confusion for some patients, who might not realize that they are receiving medications they did not request.