Common Errors

Dangerous Drug Abbreviations that Lead to Medical Injury

November 13, 2009 | Lebowitz & Mzhen

In the ongoing topic of medical error and injuries that our Maryland Medication Mistake Lawyers covered earlier this week in a previous blog, the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) recommends that in order to help prevent medical error injury and death every year, it is important that the prescribers of medication avoid the use of dangerous abbreviations in prescriptions, including those for drug names and Latin directions for use.

The current NCCMERP list of dangerous abbreviations commonly made by prescibers include:

• Mistaking “µg” for “mg” or milligrams, resulting in an overdose

• “U” is mistaken for zero or a 4, which also results in an overdose. “U” is intended to mean “Units” but with poor handwriting, it can also be mistaken for “cc” or cubic centimeters.

• “Q.D.” means “every day” in Latin. The period after the “Q” is sometimes mistaken for an “I”—and the drug is given “QID” (four times daily), which results in an overdose.

• “T I W” means three times a week. This is often misinterpreted as “three times a day”
• “IU” means International Unit, and is often mistaken for “IV” or intravenous

• “AU, AS, AD” are the Latin abbreviations both ears, left ear and right ear. These are often misinterpreted as the Latin abbreviation “OU” (both eyes), “OS” (left eye), and “OD” (right eye)

The Council also recommends that in order to enhance the accuracy of prescription writing and communications, doctors, nursing and pharmacy staff should:

• Make sure all prescriptions are legible and include notes on medication purpose—like cough, or allergies—maintaining that the proper medication is dispensed.

• All prescription orders should be written in the metric system, except for orders that use standard units like vitamins or insulin. Units should also be written out, rather than abbreviated with “U”

• Medication orders should include the exact drug name, metric weight or concentration, dosage form, with strength and concentration expressed in metric amounts.

• The NCCMERP reports that numerous errors in drug strength and dosage have occurred with the use of decimals—due to the trailing zero (1.0 mg) or the lack of a leading zero (0.1 mg). A leading zero should always be used before a decimal, and trailing zeros should never be used.

Death from Medication Error Leads to Prevention Awareness

November 10, 2009 | Lebowitz & Mzhen

As Maryland Medication Error Injury Attorneys, we have recently read data from the U.S. Food and Drug Administration (FDA) stating that in the United States, 1.3 million people are injured by medication errors every year, with at least one death reported every day.

According to the National Coordinating Council for Medication Error Reporting and Prevention, (NCCMERP), injury from medication error is an urgent, a widespread public problem, that needs to receive far more public attention. The NCCMERP estimates that 98,000 people die annually from medical errors that occur in hospitals—an amount that is greater than deaths from motor vehicle accidents, breast cancer, AIDS, even workplace injuries. Medication error can happen at any point, and result in injury—from communication, distribution, prescribing, dispensing, administering or monitoring.

A medication error is defined by the the NCCMERP as any event that is preventable, and may cause medication misusage or patient harm while the medication is being controlled by the health care professional, consumer or patient. Medication errors can happen in professional practices and during procedures, as well as in the systems of prescribing, ordering, the labeling of a product, packaging, dispensing, education, monitoring, usage, and naming conventions.

The FDA states that common causes of medication error stem from poor communication between doctor, pharmacist, and patient, with unclear product names or suffixes, medical abbreviations or handwriting, poor techniques or procedures, or a lack of understanding of directions for patient usage. Job stress or lack of training or knowledge can also lead or contribute to pharmacy error injury or misfills.

Cardiac Medication Dosing Errors Reported Most Commonly With Infants

October 23, 2009 | Lebowitz & Mzhen

As Maryland Medication Mistake Attorneys, we have been following a recent article from Cardiology Today, revealing that cardiac medication mistakes are reported most commonly with infants—in community hospitals, university hospitals, and pharmacies.

The results of a study showed that diuretics and antihypertensive agents are the most commonly reported drugs that are improperly dosed with infants—frequently prescribed by doctors for pediatric patients with heart disease. According to the article, these drugs have the potential for more widespread use because of neonatal care advances, and the increasing incidence of metabolic syndrome and childhood obesity.

Diuretics and antihypertensive agents are considered by many to be safe, because of their frequent use by doctors, but according to the research, it would be much more beneficial for the physicians, clinicians and pharmacists to have accurate information on the assessments of harm rates, and the groups of infant patients who are at particular risk—to prevent serious medical mistake errors and injury with children.

The most harmful error reports came from reported dosing error of the heart condition drugs: nesiritide, calcium channel blockers, milrinone, digozin, and antiarrhythmic agents.

According to the results from voluntary CV medication error reports that were submitted to a medication error database from the years 2003 and 2004, 50% of the total errors reported occurred in children younger than 1 year of age, and 90% of the error reports occurred in infants younger than 6 months of age.

In the 1,424 causes reported, the most frequent causes of medication error or pharmacy misfills were:

• Human error
• Improper dosing
• Missed or double doses
• Misunderstanding of drug orders
• Mathematical errors which include dilutional errors

ISMP Medication Error Cases and Prevention Checklist

October 9, 2009 | Lebowitz & Mzhen

In a prior post from this week concerning pharmacy error injury, our Maryland Medication Error Attorneys at Lebowitz & Mzhen Personal Injury Lawyers discussed a recent study published by the Institute of Medication Practices (ISMP), and the ongoing problem with drug naming standards in extended release medications.

In this study, the ISMP revealed a series of cases reported to the institute, in which drug name suffix medication mistakes have frequently occurred. This study showed specific case examples in order to establish clearer naming conventions in the industry, and improve comprehensive pharmacist and patient awareness—to prevent pharmacy error injury and misfills in the future.

The ISMP study reported these specific medication mistake cases:

• Physicians often prescribe extended release products without the correct suffix, or with a suffix that does not exist for that particular product.

• In an analysis of 402 prescribing errors published by Medscape Pharmacists, the most common type of error in the study (280 cases, 69.7%) was failure to specify the controlled release formulation.

• The ISMP received reports of cases in which pharmacists dispensed Metadate ER instead of Metadate CD—two different extended release forms of methylphenidate-UCB, a stimulant medicine commonly used to treat ADHD. In one case, a prescription for Metadate CD 20 mg was misfiled at a pharmacy, where the staff dispensed Metadate ER 20 mg.

• Some products have multiple suffixes for different formulations of the same drug. Diltiazem products for example (calcium channel blockers) are used to slow the heart rate and normalize the heart rhythm in hypertension and arrhythmia. The many suffixes for Diltiazem include SR, CD, XR, XT, and LA.

• Electronic prescribing can also lead to medication errors on behalf of the prescriber. In one case, a prescriber electronically selected metroprolol tartrate instead of metoprolol succinate because of choosing incorrectly on his PDA.

According to this report, pharmacists, practitioners, and patients should take extra care when reviewing the different formulations and medication names, especially if the medication is available in more than one dosage form.

The ISMP recommends the following medication error prevention checklist:

Patient Safety Alert: ISMP Reports Medication Error with Drug Name Suffixes

October 6, 2009 | Lebowitz & Mzhen

As Maryland Medication Error Attorneys, we have been following a recent study published by the Institute of Safe Medication Practices (ISMP), about the lack of prescription drug naming standards in extended release medications that lead to pharmacy error injury.

According to the study, although extended release drug formulations provide multiple benefits for many patients, the titles used for many medications are often confusing, and can cause patient error when the same drug is presented with several different oral dosage forms in the suffix.

Extended release drug formulations play an important role in maintaining consistent prescription therapies, by preventing the need for patients to remember to repeat dosages—delivering a steady dose of the medication throughout a specific period of time. The difficulty with many of these medications comes in the name. According to the study, drug manufacturers add suffixes or modifiers to already well-known medication names, to keep awareness of the brand, yet differentiate between the immediate-release counterparts. For example: Wellbutrin SR is a sustained release anti-depressant, whereas Wellbutrin XL is the extended-release version. Same name, different release rate.

Reminder after Reading a Story from Institute for Safe Medication Practices (“ISMP”)

February 20, 2009 | Lebowitz & Mzhen

One of the sources of information that we read regularly is published by the Institute of Safe Medication Practices. Recently, the ISMP wrote about individuals who were using a dosage cap from one over the counter medication, to measure medication from another medication.

When the measuring cups were swapped as described above, the result was that the individual taking the medication received an overdose of medication. Just as a reminder, Maryland medication error attorneys at Lebowitz & Mzhen Personal Injury Lawyers recommend that measuring cups stay with the produce that they are designed to measure so that easily avoidable, but potentially dangerous, errors are avoided.

New York Pharmacies to Provide Foreign Language Prescription Instructions

January 30, 2009 | Lebowitz & Mzhen

Maryland pharmacy error attorneys serve a number of clients who do not speak English as their first language. Some of these clients have raised the issue of not being able to receive prescriptions or dosage instructions written or spoken in their native languages from big box pharmacies. The attorneys at Lebowitz & Mzhen Personal Injury Lawyers believe that this shortcoming places a large number of citizens in danger of harmful pharmacy errors. According to the 2000 US Census, 667,357 Marylanders speak a language other than English in their homes.

As we discussed in an earlier post, Maryland pharmacists must provide medication counseling to patients when requested, and must provide written dosage instructions with prescriptions. Counseling and written instructions in English are useless to a pharmacy patient that has difficulty understanding the language.

Pharmacy Today reports that following an undercover investigation by New York Attorney General, Andrew Cuomo, Rite Aide and CVS have agreed to provide medication instructions in languages other than English at their New York locations. The investigation began after reports that pharmacies failed to provide side effect information and drug interaction warnings in patients’ native language. New York Rite Aid and CVS locations will now provide dosage and side effect information to patients in Russian, Spanish, Chinese, Italian, French and Polish. The companies also agreed to provide assistance using an over the phone translation service.

Our attorneys believe that Maryland pharmacies should follow suit and help ensure that all patients fully understand their medication dosage instructions and other relevant information.

Medication Errors Common in Hospital Outpatient Cancer Clinics

January 7, 2009 | Vadim A. Mzhen

Recently, University of Massachusetts Medical School researchers concluded that medication errors are increasingly common at outpatient cancer clinics across the country. The report reviewed nearly 11,000 prescriptions dispensed at adult and pediatric oncology clinics nationwide. The research published in the Journal of Oncology, found medication errors in 18% of pediatric visits and 7% of adult visits.

The researchers also found that patients made dosage mistakes at home due to poor communication between doctors, pharmacists and the patients. The authors concluded that better communication between oncology clinics and pharmacists would prevent many prescription errors. One of the clinics reviewed in the study utilized an electronic record keeping system. Not surprisingly, the computerized system reduced the frequency of medication errors.

The medication error attorneys at Lebowitz & Mzhen Personal Injury Lawyers suggest that our readers always check with their nurses and physicians prior to receiving any intravenous medication to make sure that the correct drug and dosage are being supplied.