Common Errors

Pharmacist Mistakenly Provides Chemotherapy Drug to Elderly Patient and Then Tries To Cover Up His Mistake

October 7, 2015 | Lebowitz & Mzhen

Earlier this month in New Zealand, a pharmacist was reprimanded by the governing professional board after it was discovered that he made an error in providing a patient with the wrong medication and then tried to cover up his mistake. According to one industry news source, the pharmacist accidentally provided an elderly patient with a chemotherapy drug rather than his prescribed immunosuppressant medication.

Evidently, the elderly patient had recently undergone a kidney transplant and was prescribed an immunosuppressant as a part of his recovery. However, when the man went to fill the prescription, he was provided a chemotherapy drug instead. It was not until three weeks later that the man returned, asking the pharmacist why his pills had changed, that the pharmacist discovered that there may have been an error. He told the patient to stop taking the drug.

Upon investigating the error, the filling pharmacist discovered that he was the one who had filled the prescription. Once he realized that he had made the error, the pharmacist failed to report the error. The Deputy Health and Disability Commissioner, who oversees pharmacists, explained to reporters that the pharmacist should have provided the patient with counseling as well as reported the error. It was not until the pharmacy owner later discovered that the chemotherapy drug supply was depleted that management knew there had been an error. He then made the appropriate report.

FDA Changes Labels on Anti-Bacterial Drug Due to Potential for Easy Mix-Up

September 29, 2015 | Lebowitz & Mzhen

Earlier this month, the Food and Drug Administration (FDA) announced a warning regarding the confusing packaging on the intravenous antibacterial drug Avycaz. According to one industry news source, the announcement was made after there were several reports of errors made in the dosing of the drug to patients. Evidently, the strength of the medication that was listed on the outside of the carton or vial was difficult to decipher for pharmacy personnel.

The confusion apparently arose because of the way that the label listed which substances were actually contained inside each package. Avycaz contains two active ingredients, ceftazidime and avibactam. The previous labels list each separate ingredient and its amount next to the drug’s name. For example Avycaz 2g/.5g means that the drug contained 2g of ceftazidime and .5g of avibactam. The new label will be more descriptive, explaining that the package contains a total of 2.5g of medication, which consists of 2g of ceftazidime and .5g of avibactam.

The Reported Errors

According to the article, there had been three reported errors since the drug’s approval back in February of this year. Two of the errors occurred as the drug was being prepared by the pharmacist, while the third arose due to the confusion in the language on the drug’s packaging. The FDA reported that at least one patient received and ingested a higher-than-prescribed dose, but there had been no adverse effects reported.

New Study Looks at Error Rates in Hospital Pharmacies

September 22, 2015 | Lebowitz & Mzhen

Earlier this month, a study was released in the American Journal of Health Systems Pharmacy that looked at error rates in hospital pharmacies. Specifically, the study considered the link between the number of incoming orders over the course of a given shift and the prescription error rate. Not surprisingly, the results of the study indicated that the busier the pharmacy, the more likely that there would be a pharmacy error made.

The study took place in Houston, Texas, between July 1, 2011 and June 30, 2012. Over the course of the study, over 1.9 million prescriptions were filled by about 50 pharmacists. In total, there were 92 prescription errors recorded.

Prescription Drug Recalls Based on Faulty Childproof Packaging

September 15, 2015 | Lebowitz & Mzhen

Earlier this month, a prescription drug designed and marketed for the treatment of some kinds of cancer, including brain cancer, was recalled because a number of the bottles that contained the drug had faulty caps. According to one industry news report, the caps of approximately 1,100 bottles of the prescription drug, Temozolomide, have the potential to crack, nullifying the childproof nature of the cap.

Evidently, the side effects of the medication are potentially severe, even for adults, and can include respiratory failure, terminated pregnancy, infertility, severe vomiting, and nausea. To ensure that the medication is not ingested by curious children, the U.S. government requires that potentially dangerous drugs like Temozolomide are packaged in childproof packaging. However, for an unknown reason, the caps on a significant number of these bottles were defective.

Specifically, the bottles that may be in danger of having cracked lids were sold between July 2013 and August 2015. The bottles at issue are the five- and 14-count brown bottles with black lettering. Merck, the manufacturer of the drug, has told patients to inspect the caps of their medication and to remove the bottles from the reach of children. In addition, Merck has suggested that all pharmacists who handle bottles of Temozolomide double check to ensure that the caps are in good condition. Of course, any bottle that does have a cracked lid should not be distributed to a patient.

Causes and Effects of Pharmacy Errors

August 14, 2015 | Lebowitz & Mzhen

Picking up a prescription at the local pharmacy is something almost everyone has the occasion to do at some point in their life. In fact, many people pick up multiple prescriptions per month. Picking up a prescription that was provided or filled in error seems to many to be one of those situations that “couldn’t happen to me.” However, as a recent article points out, prescription errors are more common than most people think, and they can often have dire consequences if they are not caught immediately.

Common Causes of Prescription Errors

The causes of prescription errors are several, but certain causes appear again and again in studies. The volume of prescriptions that pharmacists and pharmacist technicians must fill on a daily basis results in a high-stress environment where little time is left to double-check one’s work.

A rushed pharmacist is likely working to fill several customers’ orders at a time and may cut corners to save time. However, that type of behavior can increase the risk of providing an incorrect medication to a patient, such as either of the following examples:

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.