Pharmacy Errors in the News

Maryland Pharmacy Errors Involving COVID-19 Drug, Remdesivir

May 25, 2020 | Lebowitz & Mzhen

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.

New Article Sheds Light On Maryland Medication Errors

May 19, 2020 | Lebowitz & Mzhen

A recent article written by two medical professionals sheds insight into how and when prescription errors occur. According to the article, 7,000 to 9,000 people in the United States die each year as the result of a medication error. In addition, hundreds of thousands of other patients experience an adverse reaction or some other medical complication related to a medication. As we’ve written about before, these pharmacy and prescription errors can cause severe and life-threatening injuries to Maryland patients, so it is essential to be aware of them.

The article discusses the various types of medication errors. While doctors and pharmacists generally do a great job, sometimes errors do occur. A doctor might make an error when prescribing, for example, and may prescribe the wrong drug or the wrong dose. Pharmacists may give the medication to the wrong patient or accidentally tell the patient to take the medicine twice a day instead of twice a week.

These errors have three leading causes, as identified in the article. First, distraction, which accounts for nearly 75 percent of medication errors. Medical professionals are often busy and have many duties in a hospital. While speaking to patients, examining lab results, and ordering imaging studies, for example, they may be asked to quickly write a prescription. In these cases, when the job is done in haste, a medication error may occur—even with the best doctor. Second, distortion. Sometimes a doctor will prescribe a drug but use a symbol not widely recognized, or it will be translated improperly, and the actual drug administered will be slightly off. Last, illegible writing, as simple as it sounds, also leads to medication errors- a pharmacist may be unable to read what the prescription says and may thus use their best judgment and then administer the wrong medication.

12,000 COVID-19 Test-Kits Recalled, Even as Maryland Faces Test-Kit Shortage

April 27, 2020 | Lebowitz & Mzhen

Over the past two months, the COVID-19 pandemic has drastically changed the lives of individuals across the country, including Maryland residents. Experts say that in order to flatten the curve and beat the pandemic, more widespread testing is needed. Since the beginning of this crisis, test kits have been sparse, with many residents unable to get tested even if they feel ill. While there certainly is a need for more test-kits across the country, a recent story out of Washington state highlights that the need may be even greater than previously thought, as distributed test kits are being recalled for possible contamination.

According to a local news report, the Washington State Department of Health distributed 12,000 test kits to local health jurisdictions, tribal nations, and state agency partners across the state. However, the Department is now recalling these kits, after being alerted by the University of Washington Medicine that there may be possible contamination and a quality issue with them. The specific issue affects the viral transport media, which is the fluid that preserves the individual’s specimen as the test is transported. Healthcare workers noticed the issue when seeing that some vials of the transport media were an unusual color. While this issue is not at this time thought to pose a health risk to patients, the tests are still be recalled in an effort to be as safe as possible when dealing with this potentially deadly virus.

Washington state is working to replace the recalled tests as quickly as possible, but the recall comes at a terrible time, as the entire country is in dire need of tests. While it is still unclear how long this pandemic, or the related stay-at-home orders, will last, what is clear is the immense burden placed on health care workers and facilities, who are struggling to keep up with the increasing rates of infection. Unfortunately, this may mean that there is an increased risk of pharmacy errors or medical accidents occurring, which can result in catastrophic effects for Maryland patients.

Will Maryland See a Drug Shortage During the COVID-19 Pandemic?

April 20, 2020 | Lebowitz & Mzhen

The COVID-19 pandemic has affected almost all aspects of society for most – if not all – Maryland residents. Since the beginning of the crisis, necessary supplies have been in short supply. Indeed, healthcare workers have been forced to re-use supplies that are designated for a single-use and even rig their own masks because supplies were so low.

Among the newly raised concerns is a potential shortage of drugs that are needed to operate ventilators. Ventilators are machines that help those with COVID-19 breath while they are unable to do so themselves. According to a recent news report, when a patient requires a ventilator, a doctor or nurse must place a tube down the patient’s throat. To do so, medical staff need to give the patient sedative medication, pain killers, and, in some cases, medication to induce temporary paralysis. Evidently, in a letter to Vice President Pence, a spokesperson for the American Society of Health-System Pharmacists explained that ventilators “will be rendered useless without an adequate supply of the medications.”

The concern is that some hospitals are seeing demand for these drugs surge upwards of 600 percent. Part of the problem is that hospitals are attempting to secure a supply of the medication before they actually need it.

Are Maryland Doctors More Likely Than Pharmacy Technicians to Make Prescription Errors?

March 27, 2020 | Lebowitz & Mzhen

Prescription errors occur more often than many people would think. And the health professionals more likely to commit prescription errors may be surprising. A lot of attention has been given lately to overworked pharmacists who may be rushing to fill prescriptions. Yet, a new study reported an interesting finding that may have implications for Maryland patients and the Maryland prescription error victims.

According to an analysis in the European Journal of Hospital Pharmacy, the study found that doctors make more errors than pharmacy technicians in transcribing discharge medicines. One source reported that an audit was completed to compare the transcription of discharge medicines. The analysis found that pharmacy technicians had a 3.8 percent error rate, while doctors had an 18.7 percent error rate. The doctors included in the analysis made 127 errors in transcribing 678 items, including 62 errors that were considered “significant,” and one that was considered “serious.” In comparison, pharmacy technicians only made 25 errors in transcribing 654 items, none of which were considered serious, and 16 of which were considered significant.

The pharmacy technicians reportedly received training at the hospital in transcribing medications from paper-based inpatient notes to an electronic discharge system, while the doctors did not receive the same training. Pharmacy technicians were also taught to seek additional clarification of any medical issues. One of the study’s authors speculated that pharmacy technicians were approaching the task with more focus. He also said that pharmacy technicians are generally trained to clarify any issues with the doctor and another pharmacist. However, experts noted that additional research was needed.

When Are Punitive Damages Available in Maryland Prescription Error Cases?

March 20, 2020 | Lebowitz & Mzhen

Prescription errors made by pharmacies or medical institutions may be grounds for a lawsuit if the patient was injured as a result of the prescription error. A lawsuit may be filed against a pharmacist and the pharmacy for Maryland prescription errors in instances of negligent or willful conduct by the individual or the organization. In a negligence claim, a patient must show that the individual or organization failed to meet the relevant standard of care by giving the patient medication with the incorrect dosage or drug. A plaintiff must demonstrate that it was more probable than not that the pharmacist’s wrongful conduct caused the injury the patient suffered. In some instances, the wrongful conduct may be so serious as to warrant punitive damages against the individual or the organization.

In Maryland, normally, plaintiffs can recover damages for economic damages, such as medical bills, wage loss, and other losses and expenses, as well as non-economic damages, such as pain and suffering. These damages are referred to as compensatory damages, because they are meant to compensate the plaintiff.

In contrast, punitive damages are not concerned with compensating the plaintiff for their losses but rather to punish the defendant for bad conduct and to deter others from engaging in such conduct. Under Maryland law, in order to warrant punitive damages in a case, a plaintiff must show by clear and convincing evidence that the defendant acted with actual malice, or with knowing and deliberate wrongdoing.

Patients Should Keep an Eye Out for These Maryland Pharmacy Errors

March 13, 2020 | Lebowitz & Mzhen

Medical errors are estimated to the third leading cause of death in the United States. Even when they are not fatal, these errors often have a profound impact on a patient’s life. While there are many different types of medical mistakes, Maryland pharmacy errors can be among the most devastating, especially for the elderly and young children.

While there is a risk of error any time a pharmacist fills a prescription, certain situations present an increased risk. For example, according to a recent news report, the following are a few of the most common medication errors.

Zinc overdoses: Zinc is a mineral that most people consume every day in their diet. Small doses of zinc are beneficial and may help fight colds. However, it is possible to overdose on zinc. In fact, in 2019, a two-year-old was almost given a fatal dose of zinc that was 1,000 times more potent than necessary when a physician prescribed 700 milligrams instead of 700 micrograms.

Pharmacy Error Cover-Ups May Put Maryland Patients at Additional Risk

March 5, 2020 | Lebowitz & Mzhen

Pharmacists in Maryland and across the nation have an incredibly important job. However, pharmacists are human, and they make mistakes. When they are stressed, tired, distracted, or spread too thin, they may make careless errors while filling prescriptions, or ignore safety procedures in the interest of time or convenience. A recent New York Times article shows that, while some of these errors are self-reported by employees, it turns out that Walgreens—a leading pharmacy used by many Maryland residents—had been covering up these errors and information about them.

According to the New York Times, pharmacy employees told consultants about the errors—how they were tied to stress, and sometimes involved ignoring safety procedures—but the senior leaders at Walgreens told consultants to keep that information out of their presentation. The director of pharmacy and retail operations, for example, had instructed them to delete a bullet point mentioning the issue. Another senior leader removed an entire slide from the presentation, which included various findings, including instances where pill bottles contained more than one medication.

This cover-up harms patients, who are routinely being harmed by pharmacy errors related to understaffed and chaotic workplaces. Pharmacists may very well be doing their best to fill prescriptions, give flu shots, answer the phone, and tend the drive-through during their shifts, but many pharmacies employ too few employees in an attempt to cut costs, meaning that in the hustle and bustle something gets lost. Adding to the problem are the corporate performance metrics pharmacists must try to meet, which incentivize speed over safety.

Pressure on Maryland Pharmacists Putting Patients at Risk, Pharmacists Say

February 19, 2020 | Lebowitz & Mzhen

Pharmacists at the country’s biggest retail chains have written letters to state regulatory boards in recent months alerting them to what they claim are chaotic workplaces that put patients at risk, according to a recent article. The pharmacists say that the pressures put on them require that they give shots, answer phones, mange drive-throughs, take payments, and make calls in addition to filling prescriptions and counseling patients. They say that these demands in addition to meeting corporate metrics are making their jobs unsafe for patients. According to the article, surveys of pharmacists in Maryland and other states reveal that they “feel pressured or intimidated to meet standards or metrics that may interfere with safe patient care.”

For example, internal documents from CVS showed that staff members were supposed to persuade 65 percent of patients that were picking up prescriptions to sign up for automatic refills, 75 percent to have their doctor contacted for a proactive refill request, and 55 percent to switch from a 30-day supply to a 90-day supply.

One pharmacist wrote that they were a “danger to the public” in a letter to the Texas State Board of Pharmacy. Another said the situation is “absolutely dangerous” to patients. Such pressures have led to mistakes they say, including misfills. Some mistakes have led to devastating results, including dispensing a cancer drug instead of an antidepressant, leading to the woman’s death after six days of taking the medication, which allegedly led to organ failure. The family was offered a settlement in that case.

Medication Mix-Ups in Maryland Can Have Lasting Consequences

January 6, 2020 | Lebowitz & Mzhen

A recent tragic case of a wrong prescription given to a patient illustrates the potential dangers and long-term consequences of Maryland pharmacy errors. According to a local news report covering the incident, the patient was suffering from an eye infection in November 2018, and he was prescribed Tobramycin-Dexamethasone, which are eye drops to treat infections. However, after five days of putting the drops into his eyes, the patient realized that it was not the right medication.

Looking at the back of the box given to him, he noticed that it said “for ears only.” As it turns out, the pharmacy had given him Neomycin and Polymyxin B Sulfates and Hydrocortisone Otic Solution, which are ear drops, used to treat ear infections. These drops should never be put into eyes and can have long-term consequences.

After discovering the mistake, the patient went to the emergency room and saw an emergency ophthalmologist. At this point, his eyes were swelling severely and were bright red. Unfortunately, almost a year later, the patient is still suffering from the error. The glands behind his eyelids are clogged up, forming pimples and causing him pain. He has been taking medication to treat this condition and may require surgery in the future.