Health Care Technology

New Study Finds Electronic Medication Error Rates Consistent with Handwritten Prescriptions

July 1, 2011 | Lebowitz & Mzhen

In recent news that our Pharmacy error injury attorneys have been following, a new study from the Journal of the American Medical Informatics Association found that prescriptions sent electronically to pharmacies by doctors are almost as likely to have errors as the prescription medication orders handwritten by doctors.

The study examined 3,850 electronic prescriptions that a commercial pharmacy retain chain received over a period of four weeks in 2008. Out of the 3,850 e-prescriptions studied, researches found that 12%, almost 500, contained a total of 466 prescribing errors.

The researchers noted that their findings on e-prescribing error rates are consistent with their earlier study and research for error rates on handwritten prescriptions. Out of the 466 electronic prescribing errors discovered, only one-third of them could have caused patient harm or personal injury.

According to Bloomberg, the results undermine the safety benefits expected from e-prescribing, especially as the federal government paid over $158.3 million to doctors and hospitals in the beginning of 2011 to encourage doctors to switch over to electronic health records, as a way to reduce healthcare costs and eliminate medical and medication errors. The report found that although many providers are rapidly adopting electronic health records and e-prescribing, many of the expected benefits of the electronic computerized prescribing will not take effect if the electronic prescribing applications are not able to catch medication errors, or in fact cause medication errors.

Study Shows Transition to Electronic Medical Record Systems May Cause Potential Errors

June 15, 2011 | Lebowitz & Mzhen

According to a recent study published in the Journal of General Internal Medicine, although doctors and hospitals are in a mad dash to update to new electronic medical record systems (EMR)–after last year’s stimulus package promised a $27 million pay out to providers that meet the new EMR use–that transition can be risky and lead to an increase in certain types of medication errors in the months after the switch.

In the study, that our Hartford County, Maryland pharmacy error attorneys have been following, researchers found that although the change to a more streamlined system for entering prescription drug orders led to a general decrease in prescribing errors, other types of errors surfaced in the first few months after the changes were made.

Researchers reportedly followed 17 doctors who switched to new EMR systems, and found that improvements were immediately found in prescribing errors, where abbreviations that have a high potential to cause patient injury or harm dropped significantly. But rates of other prescription errors, such as medication direction mistakes were higher three months after the EMR switch over, and some rates of errors were even higher after an entire year using the system.

Rainu Kaushal, the chief of the division of quality and medical informatics at New York-Presbyterian Hospital/Weill Cornell Medical College, and the author of the study, claims that although the overall drop in prescribing errors is good, the results of the study show that there is a need for constant reassessments of the new systems—especially to prevent prescribing and medication errors in the future.

FDA Redesigns Pharmacy Packet Inserts to Avoid Medication Error Injury

May 9, 2011 | Lebowitz & Mzhen

According to a recent article in the Wall Street Journal, a new national initiative is underway to make prescription medications clearer, and to decrease the rise of medication error that lead to hospitalizations and emergency room visits from patients who take their medication incorrectly—which according to the National Community Pharmacists Association happens to three out of every four Americans.

The U.S. Food and Drug Administration (FDA) is reportedly planning to test a new one-page information sheet to replace the many leaflet inserts and medication guides that are widely used in retail pharmacy chains across the country. And the U.S. Pharmacopeial Convention, the organization responsible for setting quality standards that are enforced by the FDA for the strength, purity and quality of medicines, has also developed a new program to create national standards for prescription labels, which currently vary greatly from pharmacy to pharmacy. The national label standard would require clearer instructions on the medication dosage, the medication timing and clearly state the purpose of the medication—to reduce medication and pharmacy error injury.

Currently, in pharmacies across the country, consumers may receive three different forms of drug information and pamphlets with their prescription medication—drug package inserts that are written by the drug manufacturer with FDA approval, drug guides for specific classes of drugs and products that are required by the FDA, and third-party consumer medical information. And according to the WSJ, recent FDA studies have shown that the drug information offered to consumers does not provide reliable understanding with the people taking the drugs, and is often conflicting in instruction, or even inaccurate, which could lead to patient harm or injury.

According to a recent FDA risk-communication advisory panel, more than half of adults misread or misunderstand one or more of common drug prescription precautions or warnings. In one study, patients were found to better understand language on warning labels that was simple and specific, like “use only on your skin” as opposed to “for external use only.” For consumers with lower English literacy skills, picture icons were provided, like a sun with a black bar, with the phrase, “limit your time in the sun.”

Benefits of Robo Pharmacy Technology in Reducing Prescription Errors

April 1, 2011 | Lebowitz & Mzhen

In a recent Maryland pharmacy error injury lawyer blog entry, our attorneys discussed automated hospital pharmacies the use robots instead of people for tasks that are traditionally manual—in an effort to eliminate medication errors that could cause patient harm or personal injury.

According to the Medical Center of the University of California, San Francisco (UCSF), a hospital that recently implemented an automated hospital pharmacy–the benefits of using an robots instead of people are:

• Robots will help take over the manual medication dispensing tasks traditionally performed by pharmacists and nurses, who will in turn have more time to work with physicians to decide what the best patient drug therapy is, and will have more time to monitor each patient for any clinical responses or adverse reactions to medicine.
• The new pharmacy will provide pharmacy students with a strong training ground in the safe medication distribution systems of the future.
• The pharmacy will also enable the center to study new forms of medication delivery in order to share this groundbreaking information with other hospitals all over the country.

• Out of the 350,000 doses prepared by the robo-pharmacy since 2010, there has not been a single medication error or pharmacy misfill.

According to UCSF, the automated medication dispensing system will allow pharmacists to use their expertise in pharmaceutical care to make sure that each patients receives medication therapy that is catered to their individual needs, in a safe and effective way.

UCSF Employs New Automated Pharmacy to Prevent Pharmacy Error

March 28, 2011 | Lebowitz & Mzhen

In an effort to reduce pharmacy misfills and medication error, the Medical Center of the University of California, San Francisco (UCSF), has recently employed a series of pharmacy robots, according to recent technology news that our Baltimore-based pharmacy misfill attorneys have been following.

In the newly automated hospital pharmacy, UCSF has employed what they consider to be the most comprehensive robots on the market, to prepare and track medications and improve the safety of patients. According to UCSF, since the automated system took over in October 2010, there has not been a single error in the 350,000 medication doses prepared.

This newly automated pharmacy reportedly streamlines the delivery of medication from the prescription directly to the patient, making every step in the medication therapy process safe and effective–from deciding the best drug treatment to patient administration—in order to reduce medication error injury.

How the Robo-Pharmacy Technology works:

• The automated system reportedly prepares medications that are oral and injectable, including chemotherapy drugs that are toxic. The robots are also able to fill IV bags or syringes with medications.
• Once the computers receive a new electronic medication order from an UCSF physician and pharmacist, the robots pick the medication, package the drugs, and dispense doses of the pills that are individualized for each patient.
• The robots assemble medication doses into a thin plastic ring that contains a bar code with all of patients’ medications for a period of 12 hours.
• In the fall of this year, all UCSF Medical Center nurses will start using bar code scanners that read patients’ medication data at their bedsides–a topic our attorneys have discussed in a recent Maryland pharmacy error injury blog–to verify that the patient is being treated with the correct medication.
• A robotic inventory management system also maintains all medication products, with pharmacy warehouses that provide both refrigerated and non-refrigerated drug and supply storage and retrieval.

Study Finds Frequency of Pain Relieving Medication Errors in Hospitals

February 9, 2011 | Lebowitz & Mzhen

According to a recent study in The Journal of Pain, that our prescription error attorneys based in Rockland, Maryland have been following, medication errors involving pain relievers, or analgesics, including errors made in prescribing, are a substantial contributor to adverse patient events in pain therapy that are preventable.

The study was performed in a hospital facility with 631 beds, and found that the frequency of pain medication errors in hospitals to be 3 per 1,000 prescriptions.

Researchers at the Albany Medical Center in the state of New York reportedly found in previous research that a major number of prescription analgesic errors are preventable, occurring in all stages of the prescription medication usage process, with the primary cause being prescribing errors. The researchers then combed through a large database containing prescribing errors that had been previously prevented by pharmacists in order to pinpoint the main characteristics associated with an increased risk for medication errors.

The overall drug error rate in the study was found to be 2.87 errors per 1,000 orders with a drug prescribing error rate of .63 per 1000 that was potentially serious. Error rates with analgesics were reportedly found to be higher in pediatric orders, a topic discussed in our pharmacy error injury blog from last week.

Pharmacy, Nursing Home Sued After Pharmacy Misfill Leads to Resident’s Death

January 7, 2011 | Lebowitz & Mzhen

In recent news that our Washington D.C. pharmacy error attorneys have been following, a nursing home was fined $12,000 last month, after a pharmacy misfill caused a nursing home resident to receive the incorrect medication for 18 days, leading to her wrongful death.

The Auburn Citizen reports that according to an investigation by the New York State Health Department in March and April of 2009, Geraldine Burke, a 94-year-old resident, was given tablets of a blood pressure medicine and diuretic by three different nurses in the Cayuga County Nursing Home, instead of the thyroid medication she had been prescribed.

The tragic medication error reportedly happened as a result of a pharmacy misfill, where a technician at HealthDirect, a separate division of Kinney Drugs that provides pharmacy services for more than 100 facilities, had filled and shipped the wrong medication for Burke. The two medications reportedly had similar looking names—methimazole and metolazone—a common medication mistake that plagues pharmacies in this country, as our lawyers have reported in a recent blog.

Neither the pharmacy or the nursing home recognized the mistake, and Burke was given 11 doses of Metolazone, the diuretic. The autopsy reportedly found that Burke died from heart issues, that were a result of kidney failure, worsened by the diuretic, along with other conditions. When the facility discovered the medication error after her death, they reported it to the Health Department, where they were fined $12,000. Burke’s family sued Cayuga County for negligence, and in turn Cayuga sued HealthDirect for their pharmacy misfill.

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.