Articles Posted in Pharmacy Errors in the News

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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COVID-19 tests are now available for free at many Maryland pharmacies throughout the state. Maryland pharmacies conducting COVID-19 testing include CVS, Rite Aid, Walgreens, and Walmart, as well as some local independent pharmacies. However, the use of testing at these pharmacies raises questions about adequate staffing, particularly after such issues were raised prior to the pandemic.

According to a recent news source, Walgreens Pharmacy reported a coding error that resulted in incorrect COVID-19 testing data. The error meant that around 59,000 COVID-19 test results would be added to the state’s statistics that were not previously reported. It was not clear how many of those tests were positive and what brought about the error. According to the Department of State Health Services, there were previous issues with reporting that have caused additional issues with the state’s statistics. The state said that additional data was being reported from July when a private testing lab did not correctly report about 250,000 positive tests. The state was trying to separate the data and send the information to the appropriate county. The state reported a delay in reporting due to the errors.

The report of the pharmacy error comes just a month after CVS was fined for medication errors and under staffing. The Oklahoma State Board of Pharmacy fined the company last month after a report earlier this year that the company understaffed its pharmacies, putting patients at risk. The state pharmacy board subsequently launched an investigation and imposed $125,000 in fines. The COVID-19 testing being carried out by the pharmacies may be further burdening pharmacies and overworked pharmacists, potentially leading to medication errors and putting patients at greater risk.

Testing for COVID-19 has ramped up in recent months. While initially, tests were hard to come by, today most Maryland pharmacies are conducting tests, making them widely available. However, the surge in testing has resulted in a corresponding increase in the number of experts who are concerned that tests are providing people with false-negative results. Given the highly contagious nature of COVID-19, false negatives have the potential to cause a resurgence in the virus, putting everyone at risk.

According to a recent news report, 12 people who were tested at a Walgreen’s pharmacy were initially told that they were negative for COVID-19, only to learn later that was not the case. Evidently, the erroneous results came out of Delaware, where the local government had an agreement with Walgreen’s. In all, Walgreen’s collected over 2,900 samples at drive-up testing sites.

The tests appeared to be accurate, and the problem was not with the reliability of the test. In fact, the state Department of Health reviewed each of the Walgreen’s tests for accuracy and confirmed that “no patients who tested negative were given incorrect results.” However, 12 patients were called and told that they tested negative when, in fact, they had tested positive. The report notes that the error did not occur at the local Walgreen’s stores, implying that the lab may have been responsible for the errors.

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.

In this blog, we write a lot about Maryland pharmacy errors and the harms that can result from them. A lot of the time, Maryland pharmacy errors might not even be caught right away, and when they are, the individual affected may just decide to go deal with it individually with the pharmacy. Even if they decide to file a personal injury lawsuit due to the injuries they suffered, the case might not make the news or raise public awareness because the plaintiff is just focused on receiving compensation for their own individual injuries. Because of this, it is rare that there are public discussions about the errors that pharmacies make, and even rarer still that large retail pharmacy chains face consequences.

However, according to a recent news report, state regulators cited and fined CVS—the nation’s largest retail pharmacy chain—for conditions found at four of its pharmacies, including inadequate staffing and prescription filling errors. CVS was fined $125,000, a relatively small amount for the multi-billion dollar company. The fine, however, validated concerns that pharmacists and pharmacy technicians have about the risks of understaffing and pharmacy errors.

One of the errors found at a CVS pharmacy in the past year occurred when a developmentally disabled teenager received only one-fourth of his prescribed dose of an anti-convulsant medication. He ended up taking this incorrect dose for 18 days, during which he had uncontrollable and violent seizures. In fact, the seizures were so bad that he fell down and hit his head.

Most cases of pharmacy error involve negligent conduct and generally include careless mistakes. For this reason, punitive damages are rare in Maryland pharmacy error claims. Punitive damages are typically imposed to punish a defendant for their wrongful conduct and serve as a warning sign for others to dissuade them from engaging in such behavior.

In Maryland courts, to award punitive damages, a plaintiff has to show that a defendant acted with knowing and deliberate wrongdoing. A plaintiff must prove this by clear and convincing evidence—a higher standard than the preponderance of the evidence standard, which is generally applicable in civil cases. Thus, in many pharmacy error cases, punitive damages are not awarded because a plaintiff is unable to establish the defendant’s knowing and deliberate wrongdoing. The deliberate or intentional administration of the wrong drug is not a common occurrence. However, as a recent news report illustrates, it does occur.

Pharmacist Suspended After Purposely Giving Patient Wrong Drug

A pharmacist was recently suspended from practicing and fined after she purposely gave a patient the incorrect drug, according to one news source. Evidently, the pharmacist was working alone on a Saturday night, and a customer came in to fill a prescription for Suboxone for the patient’s opioid addiction. The pharmacist had already closed the safe where the drug was held and could not open it. The patient reportedly did not want to wait, and threatened to call the police. According to a report, the pharmacist became stressed and took some Apo-Prednisone pills and crushed them. Apo-Prednisone is commonly used to treat allergic reactions, arthritis, and severe asthma, among other conditions.

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As people across the United States and throughout the world have made adjustments due to the COVID-19 pandemic, and, likewise, Maryland pharmacies have done the same. For many pharmacists, they communicate with patients through masks and plastic barriers—if they communicate with patients at all. Medication pickups over the counter have also decreased, as many patients have shifted to other forms of delivery.

As in many other fields, pharmacies face new challenges pertaining to patient care and safety due to the COVID-19 pandemic. There has been an increase in prescriptions made over the telephone, as well as an increase in prescriptions being delivered by mail and through curbside pickup. These changes and others, implemented to maintain distance between people, can also lead to an increase in medication errors.

According to a recent industry news report, the new protocols can limit a pharmacist’s ability to identify and educate a patient, and it may make it easier to mix up patients with similar biographic information. Indeed, the Institute for Safe Medication Practices received regular reports of mistakes at pharmacy drive-throughs, even before the onset of the pandemic. For example, some prescribers use a pharmacy’s voice response system to call in prescriptions, which may not convey all information accurately. Additionally, physical barriers, such as masks and plastic barriers, when combined with an increased distance between pharmacists and patients, can also increase the chance of miscommunication.

During the COVID-19 pandemic, more and more people have been relying on delivery services and online retailers such as Amazon to supply them with their everyday needs and wants. Some popular products, such as face masks have even been on back order, as many individuals quarantined at home attempt the order them online. But Maryland residents may be surprised to hear that, in rare cases, the Amazon package left on your front porch may not be what you ordered at all. It could, instead, be the result of a major Maryland pharmaceutical error or package mix-up, like the package left on a California woman’s door earlier this month.

As reported by one local news source, a woman in California was recently excited to see an Amazon package on her front porch. As many of us would, she thought it was her order, which had been on back order and took a while to be delivered. Instead, when she opened it, she found something else entirely: seven bottles of powerful narcotics, including oxycodone, hydrocodone, and morphine, along with an invoice from the Drug Enforcement Administration (DEA). Of course, the woman wants to know how all of these powerful pills—literally hundreds—ended up in her Amazon package.

A DEA Special agent stated that he believes a pharmacy that was attempting to dispose of the drugs used a third-party shipper to send the package to Texas for proper disposal. However, the shipping labels may have been switched, leading to the unfortunate mix-up. Amazon, in a written statement, said it thought that perhaps the seller made the error, and instead of shipping the requested product they incorrectly included the drugs. Whatever the case may be, the DEA is investigating the incident. The drugs in the package are extremely dangerous, so the DEA wants to make sure there’s nothing more sinister going on.

Each year, 7,000 to 9,000 Americans die as a result of a medication error. About 1.3 million people are injured because of a medication error each year. When someone is injured because of a medication error, they may be entitled to financial compensation. A doctor, pharmacist, hospital, or another provider may be liable for their mistakes.

List Released of COVID-19 Related Medication Errors

The Institute for Safe Medication Practices recently published a list of medication errors related to the treatment of COVID-19 patients. According to one publication, the medication errors included in the list were: missed doses linked to rationing of personal protective equipment, lack of staff training in using a medicine bar code, hard-to-read remdesivir labeling, automated cabinets dispensing the wrong drug, and an inability to weigh patients to assure correct dosage.

For example, some hospitals have said that there was an increase in missed doses of medication to patients because staff was hesitant to enter patients’ rooms multiple times because they were worried they might run out of personal protective equipment. Some providers have also reported that the inability to weigh patients during telehealth visits can lead to incorrect dosages of drugs based on the patient’s weight. One hospital reported an error from an automated dispensing cabinet, where a nurse mistakenly selected and gave a COVID-19 patient a high blood pressure medication instead of a sedative, because the drug names were similar.

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Since early March, the COVID-19 pandemic has affected hundreds of thousands of Americans, including many Maryland residents. According to the Maryland Department of Health, there have been over 45,000 confirmed cases of COVID-19 in the state, although many other cases are probably unreported due to lack of widespread testing. At its worst, the illness requires hospitalization and medical treatment, and doctors and medical professionals have been working hard to treat patients as best they can. But a new report from the Institute for Safe Medication Practices (ISMP) sheds light on the concern of medication and pharmacy errors going on as doctors treat the pandemic.

According to the ISMP’s report, in the latest edition of its weekly Acute Care Medication Safety Alert, an unidentified hospital overdosed multiple COVID-19 patients due to confusion over drug labeling. The drug, Remdesivir, is an experimental treatment being used in a clinical trial for severe COVID-19 patients. The ISMP reported that the vials of the drug, however, were not clearly labeled, and that the information on it was crowded and in a small font. Exacerbating the confusion was the fact that the hospital stocked two different versions of Remdesivir, a powder and a solution, each 100 mg of the drug. The second vial was labeled 5mg/mL. These errors and confusion were not caught by the pharmacy technicians or the pharmacists, and eight patients were administered doses way above the standard.

While no adverse reactions or side effects had been reported when the ISMP’s report was published on May 14, delayed reactions may still occur, threatening the already ill patients’ health. But the story also sheds light on a potentially larger problem—overworked hospital staff, working around the clock to care for large numbers of COVID-19 patients, may be unusually fatigued, rushed, and distracted, making pharmacy errors such as this one more likely to occur. Even the smallest pharmacy error can have disastrous consequences—mixing the wrong drugs or giving an overdose can cause severe illness, injuries, or even death.

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