Articles Posted in Patient Safety

It’s no secret that the COVID-19 pandemic has overwhelmed the health care system. High rates of infection and death have sent thousands of Americans to hospitals and health care clinics, most of which were already busy treating patients before the pandemic. The country’s medical providers and health care workers are working hard every single day to try and help people and combat the virus, but the sheer amount of work and stress they are under may take a serious toll on their mental health and their ability to perform the job effectively. Recently, a hospital nurse spoke to the Institute for Safe Medical Practices (ISMP) about the impact that COVID-19 is having, and what he said has implications for how the pandemic may increase Maryland pharmacy errors.

According to an article detailing his experiences and report, medication errors have been increasing in his hospital. Because nurses are working long hours with critically ill patients in a stressful, hectic, and overwhelming work environment, medication errors are more common. However, it is likely that this pattern is not isolated to just hospitals. The entire health care system is overwhelmed right now that it is likely that the rise of medication errors is also occurring in other settings, including pharmacies.

Pharmaceutical errors can be just as dangerous as errors occurring in hospitals. Many Maryland residents rely on their local pharmacy for their medications, but when pharmacists and pharmacy technicians are stressed out and overwhelmed they may make significant errors, such as providing the wrong dosage of a medication, or even the wrong medication altogether. With the COVID-19 pandemic, pharmacies may be overwhelmed by more calls from patients than usual, or requests for more prescriptions as individuals stock up. They may also be short-staffed if a pharmacist or technician gets sick or needs to stay home to take care of a family member. All of this can negatively affect Maryland residents, who rely on pharmacists to fill their prescriptions correctly and likely to not expect to be injured from taking prescribed medicine.

The COVID-19 pandemic had changed the lives of almost every American in too many ways to count. Among those who have been the most impacted by the pandemic are medical workers, including pharmacists. Pharmacies have seen surges in volume as more people are more frequently visiting doctors and obtaining prescriptions for all types of health conditions. As the demand on pharmacists increases, so does the risk of a Maryland pharmacy error.

The Institute of Safe Medication Practices has released a list of tips that pharmacists should follow to decrease the risk of error during these challenging times. The tips are broken down into three categories:

Preventing Pharmacy Errors

When it comes to preventing Maryland medication errors, the Institute of Safe Medication Practices recommends pharmacists take the following steps:

  • Keep certain IV infusions standardized to a single concentration or dose, when possible.
  • Use visually identifiable premixed solutions for common infusions.
  • When dispensing a nonstandard concentration or a paralyzing agent, be sure to clearly label these infusions.
  • Implement frequent safety meetings and create processes for pharmacy members to double-check solutions before administering infusions.

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Maryland residents may rush to get a COVID-19 vaccine when it becomes available. Yet, as companies race to develop a COVID-19 vaccine, questions about the risks of a vaccine have been raised. All vaccines carry some risk for residents of a Maryland medication error, and according to a recent news report, many experts have speculated on the heightened risks of a COVID-19 vaccine in light of a condensed development timeline.

Experts in the public health field worry that a condensed timeline for developing and testing the vaccine might mean that it is approved without proper data and analysis. Some of those fears appear to have merit. One vaccine testing candidate did not test in animals. Another experimental vaccine was approved for China’s military before trials were even completed. A significant number of people in one vaccine trial experienced a “medically significant” adverse event. Creating a vaccine in the span of a year is “unprecedented,” according to one expert working to develop a new vaccine platform.

Some experts worry that the vaccine will not be safe or effective. A vaccine might produce unintended side effects, for example. One adverse event that had been seen with vaccines for other viruses is an antibody-dependent enhancement (ADE). An ADE is an immune reaction to the vaccine that makes subsequent exposure to the virus more dangerous by generating antibodies that encourage the virus to replicate instead of neutralizing it. One scientist said that the rare side effects of a vaccine likely will not be discovered until after the vaccine is approved.

Recently, the Pharmacy Times published an article detailing how pharmacy technicians can play a critical role in preventing pharmacy errors. Maryland pharmacy errors can cause serious injuries or illness, leaving those affected with potentially lifelong medical issues. According to the article, the role of pharmacists continues to expand to include more and more duties, meaning that pharmacy technicians are needed more than ever to fill in the gaps. Every year, there are approximately 7 million preventable medication errors. One of the most common errors is incorrect dosing—the Pharmacy Times writes that they make up about 37% of errors each year.

So how can pharmacy technicians help? The technicians are often the first line of defense and best suited to catch errors and prevent them from happening. They are often the ones who type up the prescription, and the ones who take prescriptions from the patient at the counter. They are uniquely situated to prevent pharmacy errors before they happen by double-checking medications.

One experienced pharmacy technician says that all technicians should use a set of “patient rights” while checking medications. Her five steps are designed to help pharmacy technicians systematically check for errors. First, a technician should ensure they have the right patient and ask them to identify themselves. Second, the technician should ensure they have the right medication. Third, the technician should make sure they have the right dose and instructions for how to take the medication. And finally, the technician should confirm the time of the last dose and frequency.

The novel coronavirus or COVID-19 has drastically impacted life for Maryland residents and businesses. Pharmacies across the state and the nation have been particularly affected. Pharmacies are a vital part of the healthcare system and have needed to remain open during the pandemic. However, if pharmacies are not careful, they may be doing more harm then good, by contributing to the spread of COVID-19 and causing more and more Americans to fall ill.

The Centers for Disease Control and Prevention (CDC) have been regularly updating guidance for pharmacies on their website. The guidance recommends that everyone entering the pharmacy should wear a face mask or covering, regardless of whether or not they have symptoms. This includes both customers and pharmacists. Also, pharmacists are encouraged to limit contact with customers as much as possible, by maintaining a social distance of at least 6 feet, placing the prescription on the counter for them to pick up instead of handing it directly to them, and using hand sanitizer frequently.

Importantly, the guidance also advises pharmacies to ensure that staff who are sick stay home. Pharmacists and other staff members may come to work even when they have a fever or other COVID symptoms, including body aches or a cough. While they may not want to work while sick, their employer may not have an adequate sick leave policy, and employees may fear losing their job if they request time off. Now more than ever, pharmacies need to ensure that they create policies that allow their employees to stay home when sick, and then encourage their employees to take advantage of these policies.

Technology is a crucial component of the healthcare industry. Not only do advancements in technology help pave the way for new medications and treatments, but they also lead to the development of new processes that may reduce the risk of a Maryland pharmacy error.

Recently, we wrote about pharmacist burnout being a significant contributor to Maryland pharmacy errors. While pharmacists typically work long hours, that is especially the case with the ongoing COVID-19 crisis. Thus, the issue of pharmacist burnout is a topical one in need of a solution. According to a recent news report, some experts are suggesting that pharmacists use vending machines to reduce the instances of errors.

While some countries have used vending machines for over-the-counter medications, for the most part, the United States has yet to do so. According to a proponent of the idea, vending machines could be stocked with common over-the-counter and prescription medications. The WIFI-enabled machine would have its own address to which physicians could e-prescribe medication. After a physician prescribed a medicine, the patient would go to their local pharmacy, type in their information, and receive the medication. Proponents of the vending machines agree that while some prescription drugs would be included in the machines, controlled substances would only be available through the pharmacist.

When a Maryland patient receives a prescription from a pharmacist, they typically trust that the pharmacist has given them the correct medication and the correct dosage. Unfortunately, this is not always true. Pharmacists make mistakes far too often while filling patients’ prescriptions, and these mistakes can have long-lasting consequences and lead to illness, injury, or even sometimes death. Fortunately, however, there are things Maryland residents can do to protect themselves from pharmacy errors. The New York Times recently published an article detailing five things patients should do when getting a prescription from a pharmacy.

First, patients should talk to the pharmacist dispensing their drugs. Pharmacists are knowledgeable about drugs, common issues with drugs, and how they may interact with other medications someone is already taking. Talking to the pharmacist also increases the chance that they will take a second look at a patient’s prescription, hopefully catching any errors. This precautionary step is especially useful if it is a new medication, since patients may not know what the pill is supposed to look like and won’t immediately notice errors.

Second, patients can protect themselves by taking a few seconds right inside of the pharmacy to open the bag. According to Institute for Safe Medication Practices, one of the most common pharmacy errors is dispensing a prescription to the wrong patient. Take time to check that the correct name of the patient is on the bag as well as on the box or bottle inside the bag. In this instance, patients may be able to fix a pharmacy error before it even leaves the pharmacy.

Maryland medication errors occur all too frequently and can have dire consequences for patients. The most recent study conducted by the Institute of Medicine found in 2013 that medical errors caused between 210,000 to 440,000 deaths per year. Of course, an exact number is difficult to determine because medical records are not always complete, and providers can be reluctant to disclose mistakes. In 2014, one study found adverse drug events were one of the most common medical errors in the country.

Errors involving what are known as “look alike, sound alike” (LASA) medications involve medications that sound similar or look similar in appearance, packaging, or in the names of the medications. Such drugs pose a higher risk of medication errors. As one recent article found, “Depo-” medications are often the subject of medication errors. There are several medications on the market today that begin with the prefix “Depo-.” The prefix means that the medication is administered via a depot injection that deposits the drug into tissue. However, people have consistently mixed up different “Depo-” medications with one another. Some of the most common errors are: “Depo-Provera,” “Depo-Subq-provera 104,” and “Depo-Provera Contraceptive Injection”; with “Depo-Medrol,” and with “Depo-Testosterone.”

For example, according to a recent news report, a physician mistakenly injected a patient with Depo-Provera instead of Depo-Medrol in 2015, after the medication had been inadvertently stored in a bin where Depo-Medrol was normally kept. In another case, a patient was injected with Depo-Medrol instead of Depo-Provera, which she was being given for contraception. The patient became pregnant as a result of the mistake. In that case, the staff person had mistakenly taken a vial of the drug where both drugs were stored next to each other.

It is estimated that pharmacy errors are responsible for between two to five percent of global hospital admissions. While determining the exact number of Maryland pharmacy error victims is difficult to determine due to the lax reporting requirements, experts believe that at least seven million people fall victim to medical errors each year. What’s more, the same experts believe that nearly a third of these errors are entirely preventable.

Of course, not all pharmacy errors result in patient harm. Most often, pharmacy errors that do result in harm to the patient involve at least one high-risk medication. However, the term “high-risk medication,” is somewhat controversial in that it implies that less attention needs to be paid to anything that is not a high-risk medication. Nonetheless, the term is commonly used to refer to medicines that are frequently involved in errors or present heightened risks of harm.

An industry news source recently published an article discussing what pharmacists can do to reduce the frequency of pharmacy errors. The article identifies several risk areas where pharmacists should pay extra attention.

Prescription medications are potent and potentially hazardous drugs that can cause serious illness or even death if not properly administered. While pharmacists are medical professionals who are required to obtain significant training and experience before they are allowed to serve customers, they are also human and subject to error. Because of this, Maryland patients should do all they can to reduce the chance of falling victim to a Maryland pharmacy error.

The duty to ensure that a patient receives the correct medication rests with the pharmacist. However, patients should not sit back and place complete trust in pharmacists, especially because several simple precautions can be taken to significantly reduce the chance of a Maryland medication mistake. By taking the precautions below, pharmacy patients can reduce the risk that they will become the victim of a Maryland pharmacy error.

  • Maintain a complete and accurate list of all medications: this list should be brought to all doctor’s appointments, as well as to the pharmacy when filling a prescription. Pharmacists should double-check the list a patient provides them with their records, and ensure that there are no two drugs with adverse interactions.
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