Errors in local pharmacies

Nurse Administered 70 Flu Shots with the Same Syringe

October 14, 2015 | Lebowitz & Mzhen

Earlier this month in New Jersey, a nurse who arrived at an employer’s office to provide influenza vaccinations to the employees made a “gross oversight” and reused the same syringe for all 70 vaccinations. According to one local news report, the nurse also failed to administer the proper dose of the vaccine to many of the people whom she was supposed to vaccinate.

Evidently, the nurse did change the needles between each patient but not the syringe. The health risk has been classified as “low,” but all employees who were given a vaccine were encouraged to get an HIV and Hepatitis test to make sure they did not contract either of the serious and potentially life-changing diseases.

Employees were also informed to get another flu vaccine, since the nurse improperly dosed each of the vaccines, reducing the vaccine’s effectiveness.

Pharmacy Students Participate in Mock Trial to Reduce Future Error Rates

August 28, 2015 | Lebowitz & Mzhen

Earlier this month in Auburn University’s Harrison School of Pharmacy, students and professors put on a mock trial, mimicking a real criminal law trial that alleged criminal negligence on the part of a pharmacist who signed off on an improperly diluted medication that was given to a young child. According to an article by Pharmacy Times, the mock trial is used by administrators to impart the real-world consequences that can result from a pharmacist’s mistake.

The original case arose back in 2006, when a two-year-old girl died as a result of being provided her final chemotherapy session that was improperly diluted. Apparently, rather than having less than 1% salt, the solution contained 23% salt, which ended up being a toxic dose for the two-year-old child. While it was not a pharmacist who prepared the solution, the pharmacist on duty did check the work of the technician who did prepare the solution.

After the error, the girl’s father learned that there were several other problems that contributed to the fatal pharmacy error, including the fact that the pharmacy’s computers were down that day, the pharmacy was understaffed, and there was a backlog of physician orders waiting to be filled. In the real case, the pharmacist was found to be criminally negligent because she inspected and checked off on the work of the technician. She lost her license to practice as a result. The students at the Harrison School of Pharmacy came to the same conclusion, finding that under the facts provided, the pharmacist was acting negligently on the day in question.

Two Local Pharmacies Fined a Total of $43,000 after Regulators Discover a Pattern of Errors

August 21, 2015 | Lebowitz & Mzhen

Earlier this month, two pharmacies in Saskatchewan, Canada, were fined a total of $43,000 after it was discovered that between the two pharmacies, they had misfilled roughly 20 prescriptions over the past few years. According to one local news source, regulators found several errors, including filling prescriptions for medication that was no longer prescribed, providing the wrong doses of a medication, providing pill packets with missing pills, improper labeling, and even two cases where a patient was given “mystery pills” that the pharmacist could not identify even after the error was pointed out.

Apparently, one of the pharmacy’s managers was cited for being an “absentee manager” because she was not present on a daily basis and allowed her name to be used in order for the pharmacy to keep open operations. That pharmacist was fined $8,500 and ordered not to practice in the province for two years. Additional failures were cited, including employing poorly trained assistants, not implementing a tracking system for errors and close calls, several lost or misplaced prescriptions, and failing to provide a pharmacist behind the counter during business hours. The combined effects of these errors resulted in at least 16 patients getting the wrong medication altogether.

In response to these allegations, the pharmacies told reporters that they were going through a time of high staff turnover and had to rely on temporary employees until they were able to hire permanent employees. A spokesperson for the pharmacies indicated that both pharmacies are fully staffed, and every prescription is double-checked by the pharmacist on duty.

Woman Claims Fred Meyer Pharmacy Error Significantly Reduced Her Chances of Becoming Pregnant

August 7, 2015 | Lebowitz & Mzhen

Earlier last month, an Oregon woman filed a lawsuit against the national supermarket chain Fred Meyer, alleging that an error made in one of the chain’s pharmacies greatly decreased her chances of becoming pregnant. According to a local Oregon news report, the woman is seeking damages in the amount of $680,000 against Fred Meyer.

Evidently, the woman was prescribed the fertility drug clomiphene. However, upon taking the prescription to get filled at the Fred Meyer pharmacy, the woman was provided with a similarly spelled medication instead. Upon taking just a single dose of the medication, the woman began suffering what she explain as “severe bodily injuries,” including “severe pain, shock to her nervous system, sleeplessness, fear, nervousness, nausea, balance issues, altered consciousness,” and a number of other problems. As a result, she had to stop taking the fertility medication that she was prescribed.

In a lawsuit filed by the woman against Fred Meyer, she claims that by providing her with the wrong medication, the Fred Meyer pharmacy greatly decreased her chances of ever becoming pregnant. The lawsuit was just filed in court during the past month, so a final result is not expected for some time.

Mother Catches Pharmacy Error Before Providing Medication to Her Five-Month-Old Son

July 29, 2015 | Lebowitz & Mzhen

Earlier this month in the English county of Kent, a mother of a five-year-old boy discovered that the pharmacist had included a bottle of what was later determined to be methadone. The bottle had a label on it indicating that it was supposed to have been provided to another patient. Thankfully, the mother discarded any of the medication that was in the bottle, and her son was not provided any of the dangerous opioid.

According to one English news source, the woman went to her local pharmacy to pick up her son’s prescription for his acid reflux medication. When she got home, she noticed that there were two bottles in the bag. One was her son’s usual medication and the other a bottle indicating that it contained 70 milliliters of methadone, a dangerous opioid drug used as an alternative to morphine and also to treat heroin addiction.

When the pharmacy was made aware of the mistake, their initial response was that the bottle was empty, so it created no actual health risk. However, the mother told reporters that the bottle was indeed full of a liquid that she dumped down the sink as a precautionary measure. The pharmacy issued the following statement following what they called a “highly unusual incident”:

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.

Walgreen’s Currently Facing Several Pharmacy Error Cases, Recently Settled Two Others

May 12, 2015 | Lebowitz & Mzhen

Earlier this month, a CBS news affiliate published an article discussing pharmacy errors broadly and also focusing in on the fact that Walgreen’s Pharmacy is currently facing several lawsuits based on the alleged negligence of their pharmacists. According to the report, just this year two serious pharmacy errors have occurred at Walgreen’s stores across the country.

The first was a five-year-old boy who was somehow provided with anti-psychotic medication rather than his normal allergy medicine. Not only was the provided medication the wrong one, but the dose was ten times stronger than that which should be used for a child his age and size. The boy took two doses of the unprescribed medicine before his parents noticed the mistake. His parents told reporters that “he couldn’t breathe, he couldn’t talk” after taking the two doses. His parents were later told by doctors that if they had given him one more dose they may have lost their son.

The second situation involved a 15-year-old girl who was allegedly given schizophrenia medication instead of simple antibiotics. After getting home and taking the medication, she experienced blurred vision and a racing heart. The girl’s mother told reporters that, as she stood by her daughter’s side that day, she was afraid she was going to lose her. Thankfully, both patients recovered from the medication errors.

Virginia Pharmacy Shut Down over Numerous Safety Violations

April 23, 2015 | Lebowitz & Mzhen

Earlier this month, a local Virginia pharmacy was shut down by state regulators after myriad safety violations were discovered. According to one news source, not only was the pharmacy shut down and its ability to operate suspended, but the lead pharmacist’s license was suspended.

Evidently, the pharmacy was the subject of two unannounced visits: one in May 2014 and another in February 2015. After the second inspection, regulators called into question the pharmacy’s ability to “assure the quality, sterility, integrity, safety, and efficacy of drugs dispensed, along with its ability to safeguard against the diversion of drugs.”

According to the report, regulators discovered numerous issues during their inspections, including:

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.

Woman Forced to Abandon IVF Attempt After Pharmacist’s Error

March 9, 2015 | Lebowitz & Mzhen

Earlier this month, one woman in New Zealand was forced to abandon her in vitro fertilization (IVF) attempt when she was provided the wrong dose of a necessary medication by her local pharmacy. According to a report by a New Zealand news source, the woman was undergoing a frozen egg transfer as part of her IVF treatment. As a part of that procedure, she was prescribed oestradiol valerate.

The medicine was faxed to her pharmacy. The receiving pharmacist typed in the first few letters of the medication, and the computer automatically populated the result: oestriol. The pharmacist filled the prescription for oestriol rather than oestradiol valerate.

When the woman went to pick up her prescription, she didn’t notice the mistake. She accepted the medicine from the pharmacist and began taking it according to the label’s instructions.