Hospital Pharmacy Errors

April 9, 2018

Recent Hospital Pharmacy Error Was a Result of System-Wide Failures

Earlier this month, a man in a New Zealand hospital died due to opioid toxicity after he was administered what turned out to be a fatal dose of fentanyl. According to a local news report covering the story, the error was a result of system-wide failures across the spectrum of care providers.

The victim of the error was at the hospital for a routine knee surgery. The hospital had just implemented a new e-prescribing system the month before, whereby physicians could order medication at a patient’s bedside with one touch on a computer screen. The physician overseeing the victim’s care was attending to another patient when he remembered to put in an order for the victim’s medication. The physician input the medication order and then returned his attention to the other patient.

The physician, however, failed to switch the computer screen back to the patient who was with him. Thus, when the physician entered a medication order for fentanyl patches that was intended for the other patient, the order was sent to the victim’s file.

April 2, 2018

A Look at Hospital Pharmacy Errors

by Lebowitz & Mzhen

When most people think of picking up a prescription, a retail pharmacy comes to mind. However, each year, a significant portion of the overall prescriptions filled are filled by hospital pharmacies. While there are many similarities between hospital pharmacies and their retail counterparts, there are also major differences that can lead to an increased risk of hospital patients suffering from a Maryland pharmacy error.

According to a recent news report, one of the most likely scenarios in which a hospital pharmacy error occurs is during the transition from the Intensive Care Unit (ICU). Indeed, the report indicates that nearly 50% of all patients transferring out of the ICU experience some kind of pharmacy error.

The Results of the Study

The study, which was led by a clinical pharmacy research specialist, observed nearly 1,000 patients over a one-week period. Each of the patients was transferred from the ICU to another unit within the same hospital. The results were that 45.7% of all patients experienced an error with their medication, averaging about 1.88 errors per patient.

December 22, 2017

Recent Study Shows Hospital Pharmacy Errors Decrease with More Pharmacist Involvement

by Lebowitz & Mzhen

While many Maryland pharmacy errors occur at the thousands of retail pharmacies across the state, a large portion of the state’s overall pharmacy errors still occur in medical settings, such as hospitals, rehab facilities, and nursing homes. In fact, according to a recent study, some hospital patients’ medical records reveal as many as seven pharmacy errors. Of course, while not all of these are clinically significant, the trend is still disturbing.

Due to the number of pharmacy errors across the nation, as well as the potential that these errors can result in serious injuries or death, researchers have undertaken renewed efforts to discover new methods to decrease the rate of pharmacy errors. One place researchers are focusing their efforts is on patients who take a large number of prescription medications, based on the assumption that this population is at the greatest risk of experiencing an error.

According to a recent study, when pharmacists, rather than medical staff, take a patient’s history, the number of errors in subsequent prescriptions is drastically reduced. The way that many hospitals operate is that the job of entering a patient’s history belongs to anyone who works with the patient. While this may sound effective in that numerous medical professionals are reviewing a patient’s history, the result is that no single person feels accountable. However, when a single pharmacist is given the task of entering a patient’s history, that pharmacist is the sole person accountable, and as a result, the instances of errors drastically decrease.

November 1, 2017

Recent Study Indicates that Type 1 Diabetes Patients Are at Especially High Risk of Experiencing a Medication Error

by Lebowitz & Mzhen

In the pharmacy world, it is well-known that diabetic patients are among those with the highest risk of being victims of Maryland medication errors. This is due mostly to the fact that diabetic patients are often required to take several medications in a very specific dose, as well as the fact that a failure to get the medication (or too large a dose of the medication) will likely result in an adverse health event.

According to a recent study, those patients who suffer from Type 1 diabetes are more likely than patients with Type 2 diabetes to experience a medication error. The study followed 671 diabetic adults who were admitted to the hospital. Researchers tracked the patients from admission until discharge and double-checked each administration of medication. As it turned out, about 30% of patients experience at least one error.

The most common type of error accounted for roughly 60% of all errors and was an error of omission. When this type of error occurs, a patient is not given the medication that they were prescribed by their physician. Other common error types were wrongly added medications and improperly administered medications.

October 9, 2017

Study Shows E-Prescribing Has Decreased Pharmacy Error Rates

by Lebowitz & Mzhen

In the old days, a pharmacist’s job hardly resembled what it does today. With hundreds of patients coming in to fill tens of thousands of prescriptions each month, the average pharmacist is extremely busy. This leaves them with little time to spend with each patient, and it may even result in the pharmacist rushing through important safety measures just to keep up with the workload.

The situation in hospital pharmacies is similar; with patients constantly being admitted and discharged, it can be difficult for pharmacists to keep all of the patients and medications straight. This has led hospitals across the country to rely more on technology. And it seems to be working in reducing Maryland pharmacy error rates and rates in other states.

According to a recent news article, the use of electronic health records (EHRs) and computerized prescriber-order-entry (CPOE) systems has greatly reduced the number of medication errors in hospitals nationwide. As a result, these systems have been widely adopted, with approximately 99% of hospitals using EHRs and 97% of hospitals using CPOE systems to fill at least some portions of the prescriptions filled in the hospital.

September 15, 2017

The Risks of Pharmacy Compounding Errors in Hospitals May Be Under-Appreciated

by Lebowitz & Mzhen

Maryland pharmacy errors are shockingly common and have several causes. One cause that is rarely discussed is compounding errors involving intravenous (IV) medication. The use of IV medication is very common is hospitals. Normally, a nurse comes into a patient’s room with a small bag of fluid, connects the bag to the IV in the patient’s arm, and hangs the bag up near the patient’s bed. However, patients are only seeing a small part of what goes into preparing this medication.

In reality, there are many steps that must be taken before that bag of liquid is administered to a hospital patient. According to a recent industry news source, there are a number of ways that an error can occur when a pharmacist prepares IV medication. For example, the pharmacists in the hospital’s compounding center are rarely required to conform to the same protocol, resulting in each pharmacist having their own system for creating compound medications. In a busy pharmacy environment, this can result in a pharmacist overlooking a crucial step or making some other kind of hasty error.

Of course, when dealing with serious medications, the measurements must be precise. However, too often, pharmacists are essentially “eyeballing” the correct amount of medication by using small black measurement lines on the side of a syringe. In addition, much of the process relies on hand-written notes that can be misinterpreted, resulting in an increased chance of an error.

May 22, 2017

Grandfather Receives Wrong Medication, Inducing Coma

by Lebowitz & Mzhen

Medical errors can occur in a number of situations, including by filling a prescription with the wrong pills, operating on the wrong limb, or providing medication to the wrong person. These mistakes can be devastating for patients as well as their families.

In a medical malpractice claim based on a medical error, a plaintiff has to demonstrate that the medical professional acted negligently by either engaging in a negligent act or negligently failing to take a required action. That is, a plaintiff must show that the medical provider failed to meet the applicable standard of care by failing to act in a manner in which other medical professionals would act under the circumstances.

A 74-Year-Old Grandfather Fell into a Coma After Being Given the Wrong Medication

According to one news article, a 74-year-old man went into a coma after having been given the wrong medication at a hospital. Earlier this year, the man went to the hospital with flu-like symptoms. He was diagnosed with liver cancer and admitted to the hospital. After a couple of weeks at the hospital, he was given medication that was not prescribed to him.

January 23, 2017

Registered Nurses Too Often Fail as a Last Line of Defense Against Medication Errors

by Lebowitz & Mzhen

The results of a recently published study emphasize the crucial role that registered nurses (RNs) play in maintaining accuracy in dispensing medications to patients receiving inpatient services at a hospital. The recently performed study discusses the most common medications that are subject to error, as well as the rates of harm to patients that occur as a result of errors made by RNs. Costly errors appear to encourage doctors, hospitals, insurance companies, and the medical industry as a whole to issue guidelines in the hope of preventing errors. However, whatever harm these errors cause to the medical professionals who make them, the harm caused to innocent patients is significantly worse.

The Study Confirms the High Rates of Inpatient Errors Committed by RNs

An article in an industry news source (login required) discusses the recent study mentioned above. The study found that the majority of medication errors occurred in the medical-surgical units of the hospitals where they were conducted, followed by the intensive care units and intermediate care units.

Anticoagulant drugs were the most common type of medication to be associated with a medication error, and 10% of the total errors ultimately resulted in harm to a patient. Although 10% sounds like a low number, that still adds up to hundreds of thousands of patients each year who receive some type of medication error and thousands who suffer harm as a result.

December 22, 2016

Woman Dies After Inexplicably Receiving IV Containing Deadly Dose of Paralytic Medication as a Result of Pharmacy Error

by Lebowitz & Mzhen

Most deadly pharmacy errors can be traced to a mistake that may not be justifiable or excusable but is at least understandable. Errors such as dosage mistakes that result from a misplaced or removed decimal point, problems in which a patient receives the wrong medication because of a similarly named medication, or patients get mixed up by a pharmacy employee can usually be explained. Because of the serious, sometimes deadly consequences of prescription and pharmacy errors, the victims of these mistakes should be entitled to compensation if they or their loved one is injured, disabled, impaired, or killed as a result of a medical professional’s mistake.

65-Year-Old Woman Receives Paralytic Agent Instead of Anti-Seizure Medication

The unfortunate case of an Oregon woman who died after receiving an intravenous dose of a dangerous medication from an inpatient hospital in 2014 demonstrates that some pharmacy errors and prescription mistakes defy all logical explanation and simply cannot be reasonably explained. In this tragic instance, a woman who was physically healthy when she checked herself into a hospital for symptoms of anxiety was dead two days later after receiving a medication that she had not been prescribed and that should not have been administered to any patient in the dose that she received.

According to a local news report, law enforcement authorities have recently announced that they will not pursue criminal charges against the medical professional who prepared the IV containing the paralytic agent rocuronium instead of the anti-seizure medication, fosphenytoin, that the woman’s physician had ordered. Authorities announced that it would not be in the interest of justice to prosecute the wrongdoer, while implying that they did have sufficient evidence for a conviction in the tragic death.

October 12, 2016

Medical Mistakes Are the Third-Leading Cause of Death; Many Involve Pharmacy Errors

by Lebowitz & Mzhen

Many people are unaware, but medical mistakes are the third-leading cause of death in the United States, causing roughly 365,000 deaths per year. The category of medical mistakes is a broad category, including medical malpractice, diagnostic errors, surgical errors, and pharmacy errors.

Pharmacy errors occur when a pharmacist provides a patient with the wrong dose of a prescribed medication, the wrong directions on how to take a prescribed medication, or the wrong medication altogether. These errors may occur in the hospital setting or in a retail pharmacy, but errors occurring in the in-patient setting are even more frightening and surprising because the medication is actually delivered by a doctor or nurse. One would expect that this extra layer of interaction would result in most pharmacy errors being discovered before a medication is delivered to a patient, but that is not necessarily the case.

In a recent article discussing medical mistakes generally, as well as what can be done to prevent them, the writer mentions several precautions that can be taken to decrease the frequency of in-patient pharmacy errors. The first suggestion is to have pharmacists make rounds to see all patients in the hospital along with the doctors and nurses. The author explains that while doctors are in charge of a patient’s overall care plan, a pharmacist is a much-needed consultant when it comes to any potential interactions medications may have with one another. In fact, a recent study cited by the article notes that hospitals that have implemented this plan have seen a 94% reduction of serious pharmacy errors.