COVID-19

Woman Receives Wrong Vaccine in COVID Booster Error

November 17, 2022 | Lebowitz & Mzhen

After a long period of lockdown, demand for COVID vaccines and boosters has been high. At times, the demand has exceeded both the supply of vaccines and pharmacies’ capacity to administer them. Unfortunately, when a pharmacy accepts a high volume of patients without increasing its capacity and hiring more staff, it can result in errors and mix-ups. These errors in vaccine administration have the potential to be fatal.

As a recent news article reported, a woman received the incorrect COVID vaccine booster at a Walgreens pharmacy in Rutland, Vermont. The woman received the vaccine after making an appointment for the “newest, most updated” COVID booster. Two days after her appointment, she received a call from the pharmacy informing her they had mistakenly administered an older version of the booster. The pharmacy employee told her she was still protected from COVID; however, the booster would not protect her from the newest strain. Luckily, the woman did not suffer any medical issues from the mix-up. However, given the potential for a more dire mistake, she filed a complaint with Walgreens’ corporate offices. After doing so, she claims she received an indication that other people had also received the wrong vaccine, though Walgreens denies that it happened to anyone else at the Rutland location.

Notably, the Vermont Office of Professional Regulation filed a complaint in June 2022 seeking to revoke or otherwise discipline the licenses of 32 Walgreens stores in the state, including the Rutland pharmacy. In fact, in its complaint, the Office reported that unsafe conditions at the pharmacies have increased the risk of prescription errors, vaccine administration mistakes, and the risk of harm to patients. Allegedly, Walgreens’s vaccine scheduling site had allowed such high volumes of appointments that staff could not keep up with the demand. According to the complaint, these issues resulted in the pharmacy’s inability to safely administer vaccines.

Covid-19 Vaccine Administration Errors Involving Labeling

October 14, 2022 | Lebowitz & Mzhen

After almost two years since COVID-19 vaccines become available, there are still concerns regarding avoidable administration errors that result from labeling and communication errors. When we walk into a doctor’s office to receive vaccines, we trust that we will receive the correct vaccination. But when administration errors occur for various reasons, it is important that these errors are accurately reported and that steps are taken to prevent these administration errors from happening again.

According to a recent news report, one current problem involves the labeling of the Moderna vials for the primary series for ages 6 to 11 years of age, which are still labeled as “for booster doses only.” Despite the label, these are not used for booster doses. In addition, there are two different Moderna vaccine vials that have a similar dark blue cap, which could result in an error if the vaccines are stored close together. The labeling includes the word “bivalent”, which may be more difficult to see on the Pfizer booster dose for ages 12 years and up, while compared to the Moderna label which may feature the word “bivalent” more clearly on the label. The word “bivalent” is essential to distinguish between the monovalent vaccine.

According to an interview involving the president of the Institute for Safe Medication Practices (ISMP), which was shared by Pharmacy Practice News, ISMP has received messages via Linkedin, phone, and email regarding how the labels appear to be so similar and regarding the difficulty of seeing the word “bivalent.”

Pharmacy Errors and Covid-19 Antiviral Drugs

July 10, 2022 | Lebowitz & Mzhen

As the medical industry progresses and new treatments are developed to address novel health concerns, pharmacists and pharmacy employees have a responsibility to keep up to date on the safe practices for dispensing the medications that have been prescribed. With the advent of new antiviral treatments for Covid-19 infection, pharmacy errors have unfortunately occurred. The Institute for Safe Medication Practices, a professional organization for the pharmaceutical industry, recently released a report on the misadministration of an antiviral cocktail that had been effective at battling Covid-19 infection.

According to the industry journal, the antiviral medication cocktail marketed as Paxlovid has shown promise at treating Covid-19 infection, however dispensing mistakes have been noticed at pharmacies nationwide. The largest single issue with the administration of the drug appears when it is being administered to patients with kidney disease. If a patient exhibited moderate kidney disease and was prescribed the drug, a pharmacist was supposed to remove some of the pills from the blister pack to avoid damaging the patient’s kidneys, however, this was not always done. Patients with severe kidney disease should not have been prescribed the drug at all.

What Are the Common Causes of Prescription Errors?

A mixture of poor package design, unclear instructions, and pharmacist negligence has resulted in patients receiving the wrong dosage of the medication, potentially causing harm. According to the report, some patients received their prescription with the wrong pills removed, while others were prescribed the medication while suffering from advanced kidney disease, putting them at serious risk. Although the article does not mention any serious negative patient outcomes as a result of these errors, mistakes like these can be fatal in some instances. When dispensing a new medication that a patient has not taken before, a pharmacy employee has a responsibility to confirm that the patient understands the correct dosage and method of administration before sending them home with a bottle of pills.

Preventable Maryland Pharmacy Errors in Vaccine Administration

July 5, 2022 | Lebowitz & Mzhen

Following the Centers for Disease Control (“CDC”) endorsement of the Advisory Committee on Immunization Practices (“ACIP”) recommendation that children six months through 5 years should receive a COVID-19 vaccine, many people are flocking to their doctors and local pharmacies to obtain the vaccine. However, this news comes amid a significant pharmacy worker shortage. As such, in an attempt to avoid a Maryland pharmacy error lawsuit, many chains are reconsidering whether they will provide COVID-19 vaccinations to children under the age of 5.

For instance, recent news outlets reported that Publix would not offer coronavirus vaccines to children under 5 “at this time.” A spokesperson for the chain grocery and pharmacy store declined to elaborate on their decision; however, the website indicates that the store is continuing to accept appointments for children five and older.

Despite some retailers and pharmacies’ reluctance to vaccinate young children, many pharmacies can do so safely and effectively. However, given the current supply chain issues and worker shortages, pharmacies must take steps to prevent errors. When a pharmacy fails to do so, it may be liable for any ensuing damages or injuries.

Spike in Pharmacy Error Claims Downplayed by Lax Reporting Requirements

May 3, 2022 | Lebowitz & Mzhen

A common theme of the last two years has been the burnout suffered by pharmacy employees, and the increase in patient risk that results from the lack of skilled, motivated, and healthy pharmacy staff. Although some symptoms of burnout, such as increased overtime, lack of retention, and mental health issues among employees are easily measurable, the actual number of error claims may not always be. A recently published investigative report demonstrates that a large increase in pharmacy error claims in the last two years has been obscured by lenient reporting requirements that keep such claims out of the public view. The pattern appears to apply nationwide.

According to the investigative report, several public records requests were used to discover that a large increase in pharmacy error claims corresponded with the labor issues related to the pandemic. The correlation serves as further evidence that the pharmacy industry is unable or unwilling to meet the industry standard of care that patients are entitled to and have come to expect. Pharmacies have little incentive to report instances of error when they are not required to, as public dissemination of such information may hurt the pharmacy’s bottom line. A pharmacy is a business after all.

Patients who are victims of pharmacy error and are hurt or killed as a result may have a significant claim for damages against the pharmacy or employees. Pharmacies are accountable for the conduct and mistakes of their employees, and if they are unable to safely staff their businesses, then they should not be operating under dangerous conditions. While the solutions to this problem may vary, the most important matter is that patient health and safety must come first. Maybe pharmacies need to pay more, maybe they need better training, maybe they need more safeguards, or maybe they need to temporarily close until the adequate standards can be met. Regardless of this, patients can expect adequate care and take legal action in the event of an error or mistake.

Pharmacy Staff Burnout is Dangerous to Patient Health

April 17, 2022 | Lebowitz & Mzhen

Economic factors have combined with the Covid-19 pandemic to make employment shortages in Maryland and Virginia a reality in many industries today. The medical industry is likely the most affected industry by these staffing issues, as the pandemic-related risks and responsibilities have made jobs in the medical field less desirable. Pharmacists and other pharmacy employees have been suffering from increased symptoms of burnout, as the stress and responsibility of a job in a pharmacy can be too much to handle in these times.

A recently-published article in a national pharmacy trade journal discusses the effects that staff burnout and understaffing have had on the industry, as well as the risks to patient health that will be assumed if nothing is done to address the shortages soon. According to the article, pharmacies were facing staffing issues even before the pandemic hit, and the effects of the pandemic and the broader economy have exacerbated the problems, with dangerous results. Throughout the Covid-19 pandemic, pharmacies have been a primary site for testing people for the virus. The surge in demand for pharmacists and pharmacy technicians was never quite met, and pharmacists have had a difficult time staffing their locations adequately.

With pharmacies understaffed, and remaining staff facing increased stress, hours, and workload; it is the patients who ultimately suffer. Overworked pharmaceutical assistants and technicians have been unable to spend enough time with the pharmacy customers to address their concerns with medication and screen for possible mistakes. As time moves forward and the staffing shortages continue, it is becoming even more difficult to retain employees, as many are leaving the industry entirely to seek out better opportunities.

Pharmacist Burnout Persists Two Years into the Pandemic

March 17, 2022 | Lebowitz & Mzhen

The Covid-19 pandemic has strained nearly every industry worldwide, however, healthcare workers remain one of the most affected groups by the public health crisis. Pharmacists in particular are especially burdened with extra duties related to vaccination and testing, as well as the staffing shortages and worker burnout that are affecting industries nationwide. Because pharmacists and pharmacy workers are so strained, the risks associated with burnout are real. Strained and stressed out pharmacists and other medical workers are more likely to make mistakes in their work, which may put patients at risk. A recently published news report discusses measures that one pharmacy chain is taking to address the risk of burnout among pharmacists and other employees.

According to the local news report, a major national pharmacy chain is enacting a new policy to close down their pharmacies for a 30-minute lunch break where every pharmacy employee will be given uninterrupted time to themselves to prevent the effects of burnout from affecting their work. According to company sources quoted in the news report, pharmacists and other employees have been complaining about unsustainable levels of stress and the lack of adequate breaks. The company hopes that the new policy will help their workers’ psychological wellbeing while also protecting patients from pharmacy errors.

Can Pharmacists Be Responsible for a Doctor's Prescription Error?

Yes, in some cases, pharmacists can be legally responsible for a mistake that originated with the prescribing physician. Pharmacists and their assistants play an important role in checking of the drugs that were prescribed by a medical provider to a patient are being dispensed properly. Doctors can make mistakes in choosing drugs or dosage amounts, and harmful drug interactions may not be noticed until it is too late. Because of this, it is important for pharmacy employees to be attentive and vigilant in protecting their patients.

Age-Related Vaccine Administration Errors

March 9, 2022 | Lebowitz & Mzhen

While technological advances have reduced the likelihood of most Maryland age-related vaccine errors, the COVID-19 vaccine has reignited some of these issues. Research indicates administration errors are more likely to occur to those: receiving an injection at an uncommon age, with vaccines that have age-specific dosing, and with vaccines given less frequently. The findings suggest that those receiving a vaccine off-schedule may be more likely to experience an administration error.

A typical example of this error involves the COVID-19 vaccine. The Centers for Disease Control indicates that the COVID-19 are safe and effective against severe disease. However, the public must receive the appropriate dosage at the correct time. For example, the Pharmacy Times advises the public to be aware of the rising rate of age-related COVID-19 vaccine mix-ups.

On October 28, 2021, the U.S. Food and Drug Administration (FDA) authorized emergency use of certain COVID-19 vaccines for youth between the ages of 5-11 years old. Since that time, the Institute for Safe Medication Practices (ISMP) reports receiving hundreds of mix-up reports involving the formulation for those over 12 years old and the pediatric formulation. The majority of the mix-ups occurred at physician offices, public health clinics, community pharmacies, and outpatient clinics. The reports indicate that children between 5 to 11 years old received under or overdoses, and children 12 years or older received underdoses.

COVID-19 Pandemic Induced Burnout May Impact Maryland Pharmacists

February 15, 2022 | Lebowitz & Mzhen

From March 2020 until now, the COVID-19 global pandemic has taken a toll on everyone—but especially healthcare workers. Less discussed, however, are pharmacists and the burnout they have experienced as healthcare providers, since many may assume that other frontline workers, such as physicians or nurses, are bearing the brunt of the pandemic’s impacts. Pharmacists, however, have experienced similar record numbers of burnout and exhaustion during the course of the pandemic, and mistakes resulting from being overworked could injure or even kill patients.

According to a recent news report, the COVID-19 global pandemic has taken a significant toll on pharmacists, particularly as new variations of the virus continue to emerge and mutate with no signs of slowing down. For many who work in pharmacies, the work was a great fit initially because of the drive to give back and help people. Now, many pharmacists report being burnt out and exhausted from the daily demands of work, which have been exacerbated by pandemic specific tasks that added more work to each pharmacist’s already busy schedule.

Before the pandemic, for example, pharmacists mostly focused on filling prescriptions and providing a limited number of vaccines, such as the flu vaccine. Now, many pharmacists are struggling to fill up to 250 prescriptions a day while administering COVID-19 vaccines, COVID-19 tests, and manning the phones and other customers with limited staff available.

Alert to Maryland Patients: Covid-19 Antiviral Medication May Cause Serious Reactions in Patients with Kidney Disease

January 17, 2022 | Lebowitz & Mzhen

The seriousness and speed with which the Covid-19 pandemic has overburdened the American medical system has been troubling. Because of the urgent dangers presented by the virus, drug manufacturers and pharmaceutical companies have been incentivized to develop and market preventative and therapeutic medications to address Covid-19 as quickly as possible. Because these medications are urgently needed, the Food and Drug Administration has been unable to fully test and approve all of the new drugs, instead of granting some of the emergency use authorization while the full approval is pursued.

An antiviral drug regimen that was recently developed by Pfizer has shown much promise at preventing serious cases of Covid-19 based on early studies. The FDA has granted emergency use authorization to the treatment, however, not all of the possible side effects and interactions are yet known. A recently published pharmaceutical industry report discusses possible side effects of the new treatment in patients with moderate to severe kidney disease and emphasizes the requirement for pharmacists to make dosage adjustments for such patients who are prescribed the drugs.

According to the industry report, the new drug regimen Paxlovid was developed by Pfizer and granted emergency use authorization by the FDA. The drug regimen is indicated to be used by patients who have tested positive for the virus that causes Covid-19 and is at moderate to high risk of being hospitalized or dying from the virus. Because the drugs appear to react differently in people with abnormal kidney function, the emergency use authorization included a dosage adjustment instruction for patients with moderate kidney disease. Under the emergency use authorization, patients with severe kidney disease should not be prescribed the treatment at all.