Articles Posted in Hospital Pharmacy Errors

Pharmacists and nurses have a very important job that must be taken seriously at all times. However, medical professionals are human, and it is not uncommon for a nurse or pharmacist who is comfortable doing their job to begin to engage in multi-tasking. While the ability to multi-task is seen as a good thing in some contexts, when the safety of a patient is on the line, pharmacists should keep the focus of their attention only on the task at hand. As studies have repeatedly shown, a Maryland pharmacist who multi-tasks while filling a patient’s prescription increases the risk of a Maryland pharmacy error.

Back in 2017, a woman died after she was given a lethal dose of the paralyzing agent vecuronium instead of Versed, which the doctors intended to provide her with. According to a recent news report, prosecutors released additional documentation in the 2017 case showing that the nurse made at least ten errors in the moments leading up to the time when she gave the patient the lethal dose.

Evidently, a nurse administered the lethal dose of vecuronium to the patient, who stopped breathing a short time after the medication entered her bloodstream. At the time, the nurse admitted to being involved in an unrelated conversation with a colleague when she reached for the medicine. The nurse grabbed the wrong medication and apparently failed to notice the boldface type on the packaging stating WARNING: PARALYZING AGENT.

Over the past few decades, the demand placed on Maryland pharmacies has skyrocketed. The workload of the average pharmacist has correspondingly increased. In an attempt to keep the system working efficiently, pharmacies have begun to rely more and more on technology to help with filling prescriptions. This includes checking for prescribing errors and potential adverse reactions.

One of the most notable advancements is the widespread use of electronic prescribing and medication administration. The concept behind electronic prescribing and medication administration is that doctors and pharmacists can electronically input a patient’s prescription rather than rely on a “paper trail,” as used to be the case.

As a recent article points out, however, there may be unintended consequences of the widespread use of electronic prescribing and medication administration. The study reviewed the pharmacy staff’s daily behaviors before and after the implementation of an electronic prescribing and medication administration system. According to researchers, the new system may be linked to an increase in medication errors — the study based this conclusion on several data points.

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Pharmacists are medical professionals and – although it is not always evident to patients – a significant amount of work goes into filling each prescription. Aside from making sure that the correct drug, dose, and amount of medication is provided to a patient, pharmacists are also responsible for ensuring the quality of the medicine being provided to patients, and for making sure that prescribed medication is suitable for the patient.

The vast majority of the time, pharmacists deal with controlled substances that have not just the power to help a patient, but also the potential for danger. Some of these drugs may have serious side effects or exact dosing requirements, and many of the drugs handled by pharmacists can be habit-forming or addictive.

A recent article discussed the lack of safeguards in one hospital pharmacy that allowed a physician to overprescribe painkillers in fatal or near-fatal doses to 34 patients. Typically, the hospital required a pharmacist to approve a prescription electronically before a doctor or nurse can access the medication cabinet and obtain the drug to give to the patient. In the event of an emergency, access to the medicine cabinet was allowed through a physician override. Evidently, physicians were able to access all types of dangerous medications, including fentanyl and Versed, without having to justify the circumstances of the emergency.

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Recently, the Institute for Safe Medication Practices (ISMP) issued a report asking that Maryland pharmacists, as well as pharmacists across the country, take additional precautions in the wake of a fatal 2017 pharmacy error. The ISMP is a nonprofit organization dedicated to reducing the number of pharmacy errors across the United States. In furtherance of that goal, the ISMP operates a voluntary error-reporting system. The ISMP then uses this data to work with pharmaceutical companies to eliminate the root causes of common errors such as similarly named drugs, confusing packaging, and dangerous device design.

The Error

According to the ISMP report, a patient was admitted into the ICU with a headache and vision loss. An MRI was conducted, and it was determined that the patient had a hematoma of the brain. The patient was transferred, and a full-body scan was ordered. While the radiologist was explaining the procedure to the patient, the patient indicated she had claustrophobia. The radiologist requested the patient be given a dose of Versed to help with her claustrophobia.

Evidently, the patient’s primary nurse requested that a radiology nurse provide the patient with the medication. The radiology nurse declined, stating that the patient would need to be monitored after administration of the drug. The primary nurse indicated she would send another nurse to the radiology department to monitor the patient after she was given the medication.

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Medical errors are all too common in hospitals throughout the country. In any Maryland medical error case, a plaintiff must show that the defendant was negligent in acting or failing to act in some way. There are four elements a plaintiff must prove in order to be successful in a medical negligence claim: a legal duty, a failure to perform that duty, causation, and damages.

Medical errors cases can be hard to prove in some cases because a plaintiff must show that the defendant’s actions or failure to act were the cause of the plaintiff’s injuries. This can be tricky, especially in medical error cases, because patients are often already sick and proving causation is not always clear-cut. Additionally, the issues involved in the case are often complex and involve scientific principles beyond the understanding of most people. For that reason, such cases often rely on the testimony of experts.

In some cases, an expert is needed simply to understand whether mistakes were made and who may be at fault. As one example, a recent study revealed the problem of accidental overdoses from a drug that has been used on cancer patients for many years.

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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.

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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.

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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.

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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.

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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.

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