Pharmacy Error Injury Lawyer Blog
Last updated September 29, 2026 · Reviewed by Vadim A. Mzhen
Four patients having elective joint replacement surgery at a Nashville hospital on August 14, 2026, were injected in the spine with potassium phosphate instead of the anesthetic that had been ordered for them. All four had to be transferred to a higher level of care, and one briefly went into cardiac arrest. Becker’s Hospital Review reported on August 28 that a state survey traced the error to the hospital’s own pharmacy and placed the hospital in immediate jeopardy on three federal conditions of participation.
In Maryland, an injury caused by a hospital pharmacy error is a claim against the hospital, which state law counts as a health care provider. Claims like that do not start in circuit court. They begin with a filing in the Health Care Alternative Dispute Resolution Office, and they run on the medical malpractice deadline rather than the ordinary three-year personal injury period.
Hospital pharmacy work happens where no patient can see it, which sets these cases apart from the pharmacy misfill and medication error claims Lebowitz & Mzhen Personal Injury Lawyers handles at a retail counter.
How a Look-Alike Vial Got Past Every Check
A high-alert medication is a drug that can cause serious harm when it is given in error, and potassium phosphate carries that designation. Hospital pharmacies put several overlapping safeguards around drugs like it when preparing injectable doses in batches. According to the survey report described by Becker’s, each safeguard failed on the same afternoon:
- Product selection: a technician picked vials of potassium phosphate while preparing what was ordered as a batch of the anesthetic, two drugs that come in look-alike vials with brand names that both begin with the letter P.
- Barcode scanning: the compounding software let technicians override the scan and type in vial information by hand, bypassing the drug code and manufacturer data that would have flagged the wrong product.
- Preparation: a second technician drew the medication into five syringes and labeled them as the anesthetic without visually checking the vials.
- Final verification: the pharmacist’s check took about 29 seconds, and a mismatch between the six syringes ordered and the five prepared was never reconciled.
The syringes had been prepared the day before and carried the wrong label into the operating room. When the survey team left on August 21, one patient remained on life support and three had significant neurologic impairment in the lower body. A patient under anesthesia has no opportunity to catch any of this, which is why the records of what happened inside the pharmacy are usually the whole case.
What Maryland Law Requires of a Hospital Medication Error Claim
Md. Code, Cts. & Jud. Proc. § 3-2A-01 lists a hospital among the health care providers covered by the state’s health care malpractice claims law, and it defines a medical injury as one “arising or resulting from the rendering or failure to render health care.” Under CJP § 3-2A-02, a claim against a health care provider for medical injury above the District Court’s jurisdictional limit has to proceed under that subtitle, which begins with a filing in the Health Care Alternative Dispute Resolution Office. A certificate from a qualified expert is required as the claim moves forward, and the same procedure governs any other Maryland medical malpractice claim.
The deadline comes from CJP § 5-109, which sets it at the earlier of five years from the date the injury was committed or three years from the date it was discovered. Filing in the Health Care Alternative Dispute Resolution Office counts as filing suit for that purpose, which can save a claim that is close to the line.
If you had a serious reaction during or after a procedure and no one has explained why, you can request your complete medical record, including the medication administration record, which shows what was given, when, and by whom. Where a compounded or batch-prepared drug was involved, the preparation and verification records sit with the pharmacy rather than in the chart, and a request early enough can reach them before retention periods run.
Nothing in the Nashville survey involved a Maryland hospital. The safeguards it describes are the same ones in use here, and so are the ways they fail, with override-capable scanning, batch preparation the day before, and a verification step compressed into seconds.
We represent patients across Maryland harmed by medication errors, including errors made inside hospital pharmacies where the patient never saw the drug being prepared. Our attorneys obtain the preparation and verification records, work with qualified pharmacy and medical experts, and carry the claim through the Health Care Alternative Dispute Resolution Office and into court where it goes that far. Lebowitz & Mzhen has recovered more than $90 million for injured clients, including a $425,000 recovery in a pharmacy misfill case, and we take these claims on contingency.
Questions After a Medication Error During a Hospital Stay
A hospital medication error claim depends on records the patient never saw, and on a deadline that can start running before anyone understands what happened. Lebowitz & Mzhen Personal Injury Lawyers represents patients and families throughout Maryland in these cases. Call our office at (800) 654-1949 or contact us through our website, and we will go through your claim with you at no charge.