Hospital Pharmacy Errors

Hospital Uses RFID Tags to Keep Track of Emergency Room Drugs

July 26, 2012 | Lebowitz & Mzhen

Hospitals must regularly contend with medical emergencies, such as heart attacks or allergic drug reactions, that require an immediate response. Hospitals maintain supplies for such emergencies, known as “crash carts,” that contain equipment and medications for diagnosing and, if necessary, reviving patients. Monitoring and maintaining the crash carts requires the careful attention of hospital staff. New technologies, however, allow hospitals to track crash cart inventories more efficiently. One Baltimore hospital is using radio-frequency identification (RFID) tags to ensure that crash carts are fully stocked with necessary drugs, and that all of the drugs are up-to-date.

A typical crash cart includes multiple shelves and trays, all of which must be carefully and consistently organized. Each crash cart has a cardiac monitor and defibrillator, equipment for intubating a patient, and other associated materials. The nine trays in each cart at the University of Maryland Medical Center in Baltimore contain a variety of drugs for emergency use. One tray could have anywhere between twenty-five and seventy-five items. Maintaining a supply of available equipment and drugs, and making sure the drugs are not expired, is critically important for patient safety.

Study Finds Use of Interpreters in Hospital Emergency Departments Reduces Medication Errors Almost by Half

June 28, 2012 | Lebowitz & Mzhen

A study published recently in the Annals of Emergency Medicine looked at whether the use of a trained, professional interpreter with limited-English or non-English-speaking patients in hospital emergency departments (ED’s) reduced the incidence of medication errors and other mistakes. The study compared situations in which a trained interpreter was present with situations with an amateur translator and situations with no interpreter. Patients who had the assistance of professional interpreters suffered a far lower rate of risky translation errors, particularly errors related to medication dosages. The findings could provide a helpful model for hospitals seeking to reduce pharmacy misfills due to language barriers, and also for other communication barriers like hearing impairment.

The researchers conducted a “cross-sectional error analysis” of ED visits captured on audiotape over the course of thirty months. The visits occurred at two Massachusetts pediatric ED’s. They reviewed fifty-seven meetings between doctors or other medical professionals and Spanish-speaking patients and caregivers with limited English proficiency. Twenty of the visits utilized professional interpreters, and twenty-seven had “ad hoc interpreters.” The remaining ten visits occurred with no interpreters.

In reviewing the fifty-seven meetings, the researchers counted nearly two thousand translation errors. Eighteen percent of those errors had the potential to affect the patient’s treatment. The percentage of potentially harmful errors, when broken down among the three types of meetings, revealed that meetings with professional interpreters had just over half the rate of errors as the other meetings. While twelve percent of the translation errors in visits with professional interpreters were potentially harmful, the rate for visits with amateur translators was twenty-two percent. The rate for visits with no interpreter was twenty percent. Interestingly, the visits with no interpreter at all had a lower error rate than those with an ad hoc translator.

Drug Shortages Shown to Contribute to Pharmacy Errors, While DEA Prescription Drug Crackdowns Shown to Contribute to Shortages

June 21, 2012 | Lebowitz & Mzhen

Drug shortages are affecting hospitals and pharmacies around the country. The reasons range from supply problems preventing the production of drugs, to business decisions made by pharmaceutical companies that reduce or discontinue production of certain drugs. Some critically important medications, like drugs used to treat cancer, are often in short supply.

On top of this situation, efforts by the federal Drug Enforcement Administration (DEA) to crack down on prescription drug abuse may also be contributing to drug shortages. In addition to basic problems of availability of needed medications, research suggests that drug shortages may increase the likelihood of medication errors.

Pharmacists report that they often first learn about a drug shortage when they try to order a drug from a distributor, only to learn it is backordered. This can put patients in a dangerous position, depending on the urgency of their need for the medication. In addition to cancer drugs, shortages are reportedly affecting painkillers and medications needed for emergencies, like epinephrine. These are drugs that patients need in ready supply. In the absence of a commonly-used medication, doctors may resort to a substitute medication that is less effective, or perhaps less familiar to a pharmacist.

National Patient Safety Board Would Reduce Medication Errors, Say Celebrity Supporters

June 7, 2012 | Lebowitz & Mzhen

The National Transportation Safety Board (NTSB), the federal agency that reviews highway and aviation accidents and makes recommendations for safety regulations, could serve as a model for an entity to monitor patient safety, according to a number of celebrities and other advocates. A medical journal article co-authored by actor Dennis Quaid and airline pilot Chesley B. “Sully” Sullenberg III argues for the creation of such an entity to apply lessons of previous medication errors and other mistakes towards the prevention of future problems. They cite the NTSB’s success at recommending effective revisions to airline safety regulations.

In an article published in the March 2012 issue of the Journal of Patient Safety, Quaid and Capt. Sullenberg join a medical doctor and an attorney in calling for creation of a safety board for patients. All four authors have experience as jet pilots, and all four have experience in aviation safety. Quaid additionally has endured a medical “near-death experience” with his twin children. They describe a “healthcare financing crisis” due in part to inefficient healthcare spending and waste, based on decisions made by corporate boards and administrators rather than doctors. They recommend adoption of “best practices” based on past experience, similar to the way the aviation industry has improved safety with the assistance of the NTSB.

Pharmacist Institutes Program of Double-Checking Discharge Papers, Cuts Hospital Pharmacy Errors to Near Zero

February 8, 2012 | Lebowitz & Mzhen

The hospital pharmacy services director at Minnesota’s Hennepin County Medical Center, Bruce Thompson, noticed several years ago that his staff would often discover medication errors when patients returned to the hospital after treatment. The Minneapolis Star-Tribune recounted the story of a patient who left the hospital after a kidney transplant with incorrect dosage instructions for the prescribed antibiotics. The hospital discharged a patient who had been treated for a pulmonary embolism without an essential blood thinner. Thompson wondered how common such mistakes were at the hospital, so he enlisted some colleagues to review thirty-seven patients who had been discharged from the hospital to area nursing homes during a three-month period at the end of 2008 and beginning of 2009

Thompson discovered that only three of the thirty-seven cases he reviewed had no problems. That meant an error rate of ninety-two percent, with about a third of the errors deemed “likely harmful.” The most common errors included prescriptions with incorrect dosages and duplicates or omissions of medications at discharge.

To reduce the surprisingly-high rate of errors, Thompson and the hospital administration had pharmacists review all patients’ discharge orders before the patients left the hospital. This allowed the pharmacy one last opportunity to spot mistakes and notify the patient’s doctor to resolve the problem.

According to the hospital’s report, the rate of errors dropped to almost none nine months after they started pre-release review by pharmacists. This also reduced the hospital’s readmission rate to around five percent, meaning far fewer patients were returning to the hospital for additional treatment after their discharge.

The Institute for Safe Medication Practices, which offers education and support to healthcare organizations, gave Hennepin County Medical Center one of its “Cheers” Awards in 2010. This award recognizes people, organizations, or businesses that “have set a superlative standard of excellence” in preventing errors relating to medication errors or drug incidents.

The improvement in patient safety in the hospital pharmacy is welcome news, although it is just one part of a hospital’s operations, and mistakes can occur almost anywhere. Hennepin County Medical Center ranked relatively low, for example, in a review of Minneapolis-area hospitals conducted by the U.S. Department of Health and Human Services that looked at infections resulting from central lines used in critically ill patients. This is a relatively rare procedure, and the hospital still performed above the national average. It nevertheless demonstrates that medication errors and infections do not occur solely in the pharmacies or upon discharge.

Jury Awards $12.6 Million to Teenager Who Lost Her Limbs Due to Vaccination Error

January 26, 2012 | Lebowitz & Mzhen

A jury in Miami awarded $12.6 million to Shaniah Rolle, a teenager who had to have all four limbs amputated because of a vaccination error thirteen years ago. After a five-week trial, the jury deliberated for three days before reaching a verdict. Rolle will not recover the full amount of the award, however, as the jury also found that her mother was forty percent negligent in the events that led to Rolle’s injuries. The defendant, the University of Miami’s Miller School of Medicine, will probably appeal the verdict.

As a young child, Rolle suffered from intestinal problems. Doctors concluded that they would have to remove her spleen and other organs. Since the spleen ordinarily protects the body from illness by filtering bacteria and other intruders, she would need medication to guard against infection. Her mother took her to the medical school’s pediatric unit in October 1998 for a checkup. A medical assistant gave Rolle an injection of a vaccine formulated for people without spleens. The assistant did not realize that the vaccine had expired five months earlier.

Because the vaccine failed to provide her protection against certain types of infection, Rolle became extremely ill about eight months later. At another hospital in Miami, doctors learned that she had a bacterial infection through her entire body that led to blood clots in her limbs. All four limbs had developed gangrene and had to be amputated above the joints.

Since then, Rolle has reportedly led a normal life. She attends Miramar High School in Miramar, Florida, and with the help of prosthetic limbs, she is on the school’s cheerleading squad.

Rolle’s mother filed suit against the medical school and the doctors who treated Rolle. Defense attorneys argued that Rolle would have become ill with or without the vaccine. A defense expert testified at the trial that the mother did not give Rolle enough medication to allow her to avoid infection. This was the basis of the jury’s conclusion that the mother was forty percent negligent. This means that the total award will be reduced by the amount of the mother’s negligence, so instead of $12.6 million she can recover around $7.56 million. This could be delayed even further, of course, if the hospital appeals.

Hospital Patient Mistakenly Given Drug Used in Executions

December 7, 2011 | Lebowitz & Mzhen

The family of a south Florida man has filed a lawsuit against North Shore Medical Center in Miami. The man, 79 year-old Richard Smith, died in July 2010 when he went to the hospital complaining of shortness of breath and received the wrong medication. The nurse who administered the allegedly fatal dosage received disciplinary sanctions and paid a fine, which the family does not find satisfactory.

Smith told doctors he had shortness of breath and an upset stomach. His treating physician ordered Pepcid, an antacid available over the counter. The ICU nurse instead took a vial of Pancuronium from a locked cart and put it in Smith’s IV. Pancuronium is a muscle relaxant used by the ICU when intubating a patient. In larger doses, it is used by the Florida prison system in executions as part of a three-drug cocktail. The drug does not affect consciousness, but does significantly impair motor functions. At high enough doses, a person would not be able to breathe.

According to hospital records, no one noticed Smith’s condition for thirty minutes. When hospital staff finally recognized the problem, Smith’s heart had stopped. Resuscitation efforts did not succeed in reviving him. An investigation by the state found that the nurse on duty not only failed to read the label on the medication, but failed to scan both the drug label and Smith’s patient ID bracelet. These would have alerted the nurse to the problem. Another report indicated that the nurse did not follow safeguards established for the drug cart containing the Pancuronium. The state cited the hospital for this failure. The hospital has reportedly removed Pancuronium from most nursing areas in the hospital and created a new packaging system with clearer warnings.

According to local news covering the story, the nurse still works at North Shore. He reportedly received a reprimand, paid a $2,800 fine to the state, and attended remediation courses. The hospital described this as appropriate counseling and re-training. Smith’s family disagrees, saying through their attorney that the nurse should not still be permitted to work with patients. This Pharmacy Error Injury Lawyer Blog has previously reported on cases where medication errors causing death have led to criminal convictions for involuntary manslaughter. In this instance, the consequences apparently end at professional discipline.

Pharmacist Jailed for Fatal Medication Error

November 16, 2011 | Lebowitz & Mzhen

An Ohio pharmacist spent six months in jail for a medication error that led to the death of a two year-old child. Emily Jerry’s parents took her to a Cleveland hospital in February 2006 for the last of a series of cancer treatments. Her doctors ordered an intravenous chemotherapy solution. A pharmacy technician prepared her medication with the incorrect dosage of saline, 23 percent instead of 1 percent, and supervisor Eric Cropp signed off on the technician’s work. The saline amount proved to be lethal. Emily slipped into a coma shortly after the solution was administered, and she died several days later.

Cropp lost his pharmacist license and was charged with involuntary manslaughter for Emily’s death. The pharmacy technician who prepared the solution testified to the Ohio Board of Pharmacy that she told Cropp something was wrong with the mixture, but that he approved it anyway. Evidence presented in the criminal case depicted an overburdened pharmacy and staff, indicating that the pharmacy’s computer system was down the day of Emily’s death and the pharmacy was short-staffed, leading to a backlog of orders. Testimony suggested that the pharmacy had rushed and difficult working conditions. The specific chemotherapy solution for Emily was also evidently requested on an expedited basis. Cropp was found guilty and sentenced to six months in prison in August 2009. The pharmacy tech who actually mixed the solution apparently faced no criminal penalties.

Pharmacy representatives and advocates criticized the verdict and punishment for criminalizing a human error, albeit a tragic one. The Institute for Safe Medication Practices compared the process of investigating and criminally prosecuting a pharmacist to a game of “Whack-A-Mole,” with multiple government entities each swinging at the exposed medical professional. It also claimed that the pharmacist in this case was just one part of a larger, often-dysfunctional process. As a convicted felon, Cropp will never work in a pharmacy again.

While Cropp’s criminal case was ongoing, lawmakers were reviewing the fact that Ohio did not require pharmacy technicians to be licensed by the state. Republican state senator Ted Grendell proposed a bill that became known as “Emily’s Law” in July 2007, requiring a competency test for pharmacy technicians and imposing criminal penalties on both pharmacists and technicians for performing pharmacy work without meeting the new qualifications. Governor Ted Strickland signed the bill into law in January 2009.

Patient Safety Initiatives in Maryland and Oregon are Showing Signs of Success

October 26, 2011 | Lebowitz & Mzhen

Pharmacy and medication errors in hospitals and elsewhere in the health care system create substantial risks to patients, along with errors in diagnosis and treatment, equipment problems, and others. State governments often work to promote and improve protection of patient safety in health care. Oregon, as an example, has taken a step towards improving patient safety by encouraging self-monitoring and reporting by hospitals, doctors, and pharmacies statewide. The Oregon Legislature passed a bill in 2003 that created the Oregon Patient Safety Commission, a collaboration between the health care industry and state agencies to prevent medical errors. The state estimates that, last year, at least 34 deaths throughout Oregon resulted from medical errors. The program encourages the submission of detailed reports on medical errors to the Commission, which compiles the data and keeps track of statistics and trends.

Oregon has 58 community hospitals, and all of them have agree to submit reports. Most of the state’s hospitals have been reporting since the program started in 2007, and only two hospitals were still holding out as of last year. According to the Oregon Association of Hospitals and Health Systems, hospitals are reporting errors at a rate to similar to that in states that mandate reporting. The system is far from perfect, though. Because of its voluntary nature, hospitals do not always provide patients with notifications of errors, even if they report those errors to the state. Hospitals also do not report every error known to have occurred.

Pharmacies and surgical centers in Oregon have some catching up to do. According to an investigation by the Oregonian newspaper, the state’s pharmacy board receives about 600 complaints per year, but the Commission only received six error reports from pharmacies between the fall of 2008 and the summer of 2011. About half of Oregon’s licensed surgical centers have agreed to participate with the Commission, and of those who have agreed, only two-thirds actually reported anything in the past year.

Patient Death During California Nurse Strike Possibly Due to Medication Error

September 28, 2011 | Lebowitz & Mzhen

A patient at Alta Bates Summit Medical Center in San Francisco, California died over the weekend, allegedly due to an incorrect medication dosage from a replacement nurse. About 23,000 nurses across California went on strike on Thursday, September 22, 2011 due to a dispute between the nurses’ union and the healthcare network that runs Alta Bates and other hospitals. The strike was meant to last one day, but the nurses found themselves locked out when they tried to return to work Friday. The lockout continued through the weekend. The hospital brought in replacement nursing staff to cover the shifts for the union nurses.

The patient was a 66 year-old Oakland resident who had been receiving treatment at Alta Bates since July 2011. Preliminary findings indicate that her death resulted from the wrong dosage of a medication, which was administered by one of the replacement nurses.

The nurses’ union, the California Nursing Association, has questioned the qualifications of the replacement nursing staff. The American Nurses Association, which represents nurses nationwide, allows nurses to strike if the intent is to advocate for changes in hospitals to benefit patient health. The ANA’s ethics rules requires nurses going on strike to provide advance notice of their plans and to take steps to minimize any potential harm to patients. The purpose of Thursday’s strike was to protest contract concessions demanded by the healthcare network that, according to the union, would negatively affect patient safety.

Hospital officials have defended the replacement nursing staff, saying that they are all highly experienced, and that the hospital “did not skimp on any of the nurses.” While the question of liability and “fault” may take some time to resolve, this incident clearly demonstrates the difficulties inherent in patient safety in hospitals, especially where medications are concerned. A hospital mired in confusion carries a great risk of pharmacy errors.

This Pharmacy Error Injury Blog has previously noted the high rate of risks for medication errors in hospitals despite efforts at accountability among doctors and nurses. This incident in San Francisco demonstrates a phenomenon noted by a recent study from Johns Hopkins, which found an increased risk of medication errors in hospitals that use temporary doctors and nursing staff. The study concluded that a lack of familiarity with a particular hospital’s systems and procedures among temporary staff can lead to an increased number of medication errors.