Common Errors

Medication Therapy Management and the Prevention of Medication Error

December 28, 2010 | Lebowitz & Mzhen

According to the American Pharmacists Association (APhA), medication-related events are a massive problem to this country’s public health and well being. As our Baltimore medication error injury attorneys have reported in a related blog, according to the APhA, 1.5 million people are injured by medication errors every year, that cost around $177 billion in personal injury and death, and could be preventable.

Ed Webb, associate executive director of the American College of Clinical Pharmacy, recently stated that prescribed medication is only beneficial if taken correctly, and if medication therapy is not managed well, it can do harm. Webb, along with other experts, recommends medication checkups, known in the business as medication therapy management, or MTM.

As our Baltimore pharmacy error attorneys also discussed recently in a blog, more and more people are being encouraged to make appointments with their pharmacists as well as their doctors to discuss the medications that they take in an effort to prevent medication error, pharmacy misfill or patient injury.

Patients reportedly often end up saving money when meeting with pharmacists, by switching prescriptions to generic drugs instead of brand-name, or dropping medications that they may no longer need. Other patients are often able to eliminate medication side effects with help from a pharmacist on the best time to take the medication, possibly changing to a different drug, or avoiding a potentially dangerous mix-up of drugs, which can lead to expensive trips to urgent care or emergency rooms and result in personal injury.

CVS Pharmacy Misfill Mixes up Child’s Hyperactivity Drug with Methadone

December 22, 2010 | Lebowitz & Mzhen

In recent news that our Baltimore pharmacy error attorneys have been following, a nine-year-old child in Las Vegas reportedly received an accidental pharmacy misfill at a local CVS Pharmacy, after his hyperactivity medication was filled with methadone, a drug frequently used to treat withdrawal and dependence problems with people who are addicted to Heroin.

Tammy Jordan claimed that her son, Kyren, an active kid, is sometimes prescribed the drug Methylphenidate, to help treat his hyperactivity disorder. Jordan claims that she didn’t even check after picking up the prescription from CVS, as this was a common medication for her son.

According to KTNV.com, Jordan reportedly noticed that after Kyren had been taking the prescription misfill for an entire month, he couldn’t sit still, and couldn’t tell his mother why. A few weeks later, after dropping off the medication at Kyren’s school, the nurse called Jordan, and was alarmed that Kyren was taking Methadone and not Methylphenidate—the medication that the nurse regularly gave to the child.

Jordan claims that she was shocked by the medication error, and stopped Kyren from taking any more of the drug. He reportedly went through a period of withdrawal, but made a full recovery with no injury. Once Kyren recovered, she reportedly approached CVS, where the pharmacist on duty took the bottle and peeled off the first label, revealing that another label had been mistakenly placed on top of Kyren’s medication.

The state Board of Pharmacy is reportedly looking into the prescription drug misfill, to decide what exactly what happened, and how to prevent prescription filling errors from happening in the future.

In a recent blog our Baltimore pharmacy error injury lawyers discussed tips for preventing pharmacy misfills when picking up your child’s prescription at the pharmacy, including verifying the medication, always double checking the name on the prescription, the dosage, usage, and whether the drug is suitable for your child’s weight and size.

Healthcare Center Sued for Wrongful Death After Man Dies from Pain Medication Overdose

December 1, 2010 | Lebowitz & Mzhen

In recent news that our Washington D.C. nursing home attorneys have been following, a medication error lawsuit has been filed against a local hospital in Salt Lake City, after a patient died from receiving an alleged overdose of a potent pain medication.

According to Deseret News, Clarence Burton was admitted to Woodland Care Center on August 1, 2008, to be supervised by nurses while he underwent radiation and chemotherapy treatment at St. Mark’s Hospital. Burton was reportedly fighting bone cancer, and had been prescribed the brand name pain medication patches Duragesic, containing the strong medication fentanyl to help him deal with the pain.

The lawsuit alleges that the care center staff members made a grave medication mistake when they failed to follow the doctor’s prescription, which was to give Burton one 50-milligram pain patch every 72 hours. The manufacturer of Duragesic also advises to wait 72 hours before increasing the pain medication dosage. Instead, the staff allegedly applied three pain medication patches on Burton’s neck, and he was found a few hours later, lying the floor in complete cardiac arrest.

When Woodland was met by the emergency personnel, they were reportedly unable to revive him, and he was taken to the hospital, where he was given another drug to counteract the fentanyl overdose. Burton was later resuscitated, but according to the lawsuit, remained unresponsive, as he had sustained sepsis, renal insufficiency, and elevated liver function as a result of the alleged malpractice. Burton was taken to another care center six days later, where he died on August 9, 2008.

Glaxo Pays $750M in Settlement for Violations in Pharmaceutical Drug Manufacturing

November 23, 2010 | Lebowitz & Mzhen

Our Washington D.C. pharmacy error injury attorneys have been following the recent announcement by the U.S. Department of Justice (DOJ) that GlaxoSmithKline (GSK), a research-based pharmaceutical and healthcare company, has agreed to pay the government $750 million in an effort to settle criminal and civil charges alleging that the company sold adulterated drug products to Medicaid and other government health plans, risking the health and safety of consumers.

Cheryl Eckard, a former Quality Assurance Manager for GSK, was reportedly assigned to visit the company’s Cidra, Puerto Rico plant in 2002 with a group of 100 experts and scientists to survey violations cited by the FDA in drug manufacturing. Eckard reportedly discovered major manufacturing and quality testing issues that went beyond the FDA violations, and that could have caused medication error or patient harm.

Deficiencies found in the plant include the release of a topical antibiotic Bacrtoban ointment used to treat skin infections on babies that contained microorganisms, and the production of the Kytril injection, used by cancer patients for nausea that was reportedly not sterile. Deficiencies were also found in the manufacturing of the antidepressant Paxil CR tablets, causing the drug to have the incorrect amounts of active ingredients. Another manufactured drug, Avandamet, a derivative of the drug Avandia, used to treat diabetes, were reportedly found to be superpotent and subpotent.

As the Cidra plant was reportedly GSK’s top manufacturing facility in the world at that time, bringing in $5.5 billion every year, Eckard found that GSK could not assure that they produced contamination-free products that were made in accordance to the drug formula registered with the FDA. She reportedly advised GSK managers to close the plant, and submitted an extensive report to the compliance department at GSK, who claimed her report was unsubstantiated.

Maryland Hospitals Decrease Medication Error with New Technology

November 18, 2010 | Lebowitz & Mzhen

According to a study that our Baltimore, Maryland attorneys reported on in a recent blog, thirty-five Maryland hospitals increased their median safety over the past ten years, reducing medication error and patient injury with new technology.

In Maryland’s Peninsula Regional Medical Center, the hospital is reportedly improving the tracking of patient records and the prevention of complications with drugs that can lead to medication errors, when medication is improperly administered, through technology. The hospital is reportedly using a barcode system that our Maryland medication error attorneys also discussed in a recent blog, that removes the chance for medication errors by using barcode scanners to ensure that the barcodes on the prescription match the patient’s bracelet wrist-band and the medication, as well as the dosage.

The hospital also uses “Rosie” the Pharmacy Robot, who joined the pharmacy in 1999 and fills 2,500 doses daily from the pharmacy with 100% accuracy. By using barcode technology, Rosie finds a patient’s drug that has been ordered by the physician and then entered by the pharmacist, and prepares the medication with a special barcode for patient delivery. The robot reportedly even notes when the medication stocks are running low and creates new orders electronically.

Other Maryland patient safety initiatives include the use of electronic medical records, Acudose Medication Storage Cabinets, where security codes are used and any drug taken from the cabinet is recorded, and Online Point of Care Wireless Patient Charting. The hospital is reportedly working on eliminating all human error, and continues to invest in new strategies and procedures as well as technology to reach “zero errors” to protect the health and safety of patients.

Study Finds Maryland Hospitals Improve Safety and Health Standards

November 17, 2010 | Lebowitz & Mzhen

A recent study, published in the medical journal, Quality & Safety in Health Care, reportedly found that thirty-five Maryland hospitals showed notable improvements in the safe delivery and administration of drugs to patients in hospitals.

The study was performed on behalf of the Maryland Patient Safety Center, whose aim is to create health care in Maryland that is safer than any other state in the country by reducing adverse medication events, improving patient safety, and by focusing on improving the care systems in Maryland hospitals.

Released in October of last year, the study concluded that when measuring the delivery of medication, the combined Maryland safety scores for these hospitals dealing with acute care rose by almost 10 percent in over two years, reducing occurrences of medication errors.

By comparing safety data on medication and drug use between the years of 2005 and 2007, the authors of the study reported that Maryland hospitals received the highest scores in the packaging of drugs, the standardized distribution of drugs and safe labeling, safe storage of drugs, and keeping chemicals that are hazardous away from drug-preparation and patient areas, to reduce patient injury or harm.

Study Shows Barcode eMAR Technology Can Help Reduce Medication Errors

November 3, 2010 | Lebowitz & Mzhen

In a recent blog, our Maryland pharmacy error injury attorneys discussed reducing medication error and patient injury with barcode electronic systems, that link barcodes on the patient’s wrist bracelet with the patient’s electronic records and prescriptions, to ensure that the medication and dosage match the prescription for the patient.

According to a recent study that the Agency of Healthcare Research and Quality (AHRQ) in Rockville, Maryland, has funded, barcode technology, working together with eMAR, the electronic medication administration system, can help reduce medication errors by over 50%. The study was published earlier this year, in the May issue of the New England Journal of Medicine.

Barcode eMAR combines technology to ensure that each patient is given the proper medication with the correct dosage at the right time, in order to prevent medication errors or patient injury. When this combination of technology is used, before administering the medication, the nurses must scan the barcode on the patient’s wrist bracelet, and then scan the medication. If both barcodes don’t match the approved medication, or the timing is not correct for the patient’s next dose, an alert is issued by the system. If the patient’s medication is overdue, warnings are also sent out to the nurses.

In the study, researchers at Boston’s Brigham and Women’s Hospital compared 6,723 medication administrations given on hospital units before the barcode eMAR was introduced with the 7,318 administrations of medication given after the barcode system was introduced.

Children’s Hospital Launches Initiative to Prevent Medication Error

November 1, 2010 | Lebowitz & Mzhen

After two children died from medication errors at Seattle Children’s Hospital over a period of 18 months, as our Baltimore, Maryland medication error injury lawyers recently discussed in a blog, the staff of the hospital held a special ‘Zero Errors Initiative’ Patient Safety Day on Saturday, to prevent tragic medication errors like these from happening to children in the future.

According to the Seattle Post Intelligencer, over 550 physicians, staff, pharmacists, and nurses convened at the hospital for special patient safety sessions, focusing on training designed to prevent future incidents of medication and pharmacy errors.

Pat Hagan, the president of Children’s Hospital reportedly stated that these tragedies and the harm that was done to these children by the hospital will never be forgotten. Hagan said this has been a profound tragedy for the families, and for the hospital staff, and that this feeling will propel the hospital to continue to find ways to prevent life-threatening medication errors from happening.

The sessions during the safety training day included topics such as strengthening the safety of verbal orders, standardizing children’s medications located on care units, prescribing, dispensing and administering medications that are high-risk, improving communication between providers when handing off patients, and patient safety training with the use of simulation.

Pharmacy Error Gives Wrong Drug to Premature Babies

October 29, 2010 | Lebowitz & Mzhen

In a blog from earlier this year, our Washington D.C. pharmacy error injury attorneys discussed Dennis Quaid’s high profile lawsuits against Baxter Heathcare Corporation, that were filed after his newborn twins were given a near-fatal overdose of Heparin, a blood thinner. The medication error was allegedly due to a mistake with Baxter’s look-alike labels, and the twins were given 10,000 units of Heparin instead of 10 units of Hep-Lock, originally prescribed to treat a staph infection.

In a recent medication error in Saskatchewan, Canada, four premature infants in the neonatal intensive care unit at Royal University Hospital were prescribed the drug Heparin, the blood thinner used to prevent clots, and were mistakenly given insulin with the brand name Humulin R, and that was reported to have a similar looking label.

The pharmacy mistake was discovered because all infants were in the same unit, and their conditions were reportedly deteriorating in similar ways due to the insulin, which caused them to have dangerously low blood sugar levels. The infants mistakenly received the insulin in their IV infusion instead of Heparin.

In the review of the incident, the mistake was reported to be caused by an over crowded space in the pharmacy, a possible labeling error that was missed during the many safety checks, or an issue of look-alike labels.

Reporting Children’s Medication Errors Can Help in Prevention

October 1, 2010 | Lebowitz & Mzhen

A recent news article reports that medication errors are among the most common mistakes made by healthcare practitioners—and also among the most under reported.

In a tragic medication error from last year, a child at Seattle Children’s Hospital died from a medication error allegedly involving Calcium chloride. The hospital reported its mistakes to the health department and has acknowledged them publicly. Calcium chloride, the medication that reportedly caused the child’s death, is listed on the Institute for Safe Medication Practices’ (ISMP) class of pharmaceuticals as one of the institute’s “high-alert” medications.

According to the Agency for Healthcare Research and Quality (AHRQ), medical errors are one of the leading causes of death and injury in the U.S. The AHRQ reported in a recent study that rates for potential adverse drug events in hospitals were three times higher with children than adults, with an even higher rate for infants in intensive care units.

According to Dr. Allen Vaida, executive vice president of the Institute of Safe Medication Practices (ISMP), acknowledging medication errors and reporting them is the most important step toward prevention. Vaida claims that children are especially vulnerable to drug overdoses in hospitals because of calculation errors that can occur with medications. Nurses must administer the medication dosages according to a child’s body weight and other necessary factors, that can lead to medication mistakes. He claims that in situations like this, it is important to share information about the medication errors that do occur, as reporting them can prevent errors from happening in the future.