In most professions, when someone makes a serious error that affects the health or safety of another person, it becomes public knowledge. Indeed, we often read in the news about reports of doctors, police officers, and politicians who make questionable judgment calls. The fact that these lapses in judgment become public knowledge allows for the public to better understand the errors and encourages brainstorming about how to reduce those errors in the future through better policy-making and enforcement.

Mixed PillsPharmacists, however, do not face mandatory reporting requirements in much of the country. In fact, in most states, pharmacists are given discretion about when to report most errors. Interestingly, Maryland is ahead of the curve in requiring that certain adverse patient-related events, including medication errors, be reported within five days by medical professionals, including pharmacists.

The Seriousness of Pharmacy Errors

The Food and Drug Administration estimates that medication errors cause more than one death a day and injure over 1.3 million people annually. While not every prescription error will result in a serious injury or death, it is important to realize that the effects of a pharmacy error may not be immediately apparent. In some cases, medical experts are required to establish which, if any, consequences a patient who has been provided the wrong medication may face in the future.

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Earlier last month, a news article discussed a recently filed case brought by a woman who was provided the wrong medication by a national pharmacy chain. According to the news report, the woman suffered from restless leg syndrome and was provided a prescription for Ropinirole by her physician. She called in the prescription to a nearby pharmacy, picked up her pills, and took them home. She took the first dose later that night.

PillsAfter taking the first dose of the medication she was provided by the pharmacist, the woman started feeling odd and suffering from serious nightmares. She explained that she was hallucinating and didn’t know what was going on, and it felt as though her limbs were detaching from her body. Her husband told reporters that his wife awoke in the middle of the night, telling him strange stories that did not make any sense.

On the next day, the woman’s daughter noticed that her mother was not acting normally and checked the pill bottle. Her mother’s name was on the outside of the bottle, and the correct medication name and dosage was on the front of the bottle; however, when she opened the bottle, the pills did not match the label. The bottle contained Risperdone, a powerful anti-psychotic used to treat schizophrenia. After the woman discovered the error, she was taken to the hospital and connected to an IV to flush her system.

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Earlier this month, a British news source published an article discussing the 2016 death of a man who was provided the incorrect prescription just days before he died. According to the report, the man had been receiving medication for type II diabetes, heart problems, and glaucoma. He had filled the prescriptions in the past with no problem, but in May of last year he was provided another patient’s prescription. Apparently, the packet containing the pills contained another customer’s prescription with his name on seven different labels; however, the victim’s name was printed on the outermost packaging.

Silver PillsAn investigation was conducted into the fatal pharmacy error, and it was discovered that the filling technician had opened the interior packet of pills, added additional requested pills, and then sealed the package back up. Apparently, the technician did not notice that the name on the seven labels inside the packaging and the name on the outside packaging did not match. And neither did her supervisor.

After the error occurred, but before it was discovered, the man began complaining of chest pain and having a difficult time breathing. Two days after the error, he passed away. The coroner’s report indicated that the prescription error at least “hastened” the man’s death. However, the prosecuting authority determined that there was insufficient evidence to pursue criminal charges. Since the accident, the branch where the error occurred has stopped assembling medication packets on location.

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By any account, pharmacists do not have an easy job. They often fill hundreds of prescriptions per shift, meet with dozens of clients for consultations, and must also maintain their internal inventory systems throughout the day. Pharmacists are human, and with these burdens being placed upon them day after day, it is no surprise that the rate of pharmacy errors is as high as it is.

Blister PackAccording to one news report that discussed a study it conducted of Chicago-area pharmacies, 52% of all pharmacies surveyed failed to warn patients about a dangerous drug interaction. This study didn’t take into account other types of pharmacy errors, such as providing the patient with the wrong dose of medication or the wrong type of medication altogether. The news agency looked mostly at both independent and national-chain pharmacies, discovering that CVS had a failure rate of 62%, Walgreen’s had a failure rate of 30%, and independent pharmacies had a failure rate of 72%.

Due to the concerns surrounding pharmacy errors, lawmakers have recently started to try to implement stricter guidelines for pharmacists. The proposed changes would limit a pharmacist’s workday to 8 hours, require pharmacists take two 15 minute breaks and an hour lunch, and limit the number of prescriptions filled per hour and per shift. Despite the undeniably high error rates, some pharmacies and pharmacists have opposed the newly proposed laws.

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In day-to-day life, when someone admits to doing something wrong, they normally acknowledge that they are responsible for the consequences. However, in pharmacy error cases, that is not always the case. In fact, it is not uncommon for a pharmacist to acknowledge that a prescription mistake was made and then deny all legal liability. Pharmacists are able to do this due to a legal requirement inherent in pharmacy error cases called causation. Causation requires that the injured party prove their injuries were caused by the pharmacist’s mistake.

White PillsIn a recent case filed by an Ohio man, the pharmacy allegedly responsible for an error that left the man with chronic kidney failure seems to be denying that they are legally responsible for his injuries, despite acknowledging a mistake was made.

According to a recent news article detailing the man’s plight, he went into the defendant pharmacy to fill a three-month supply of blood-pressure medication called Labetalol. However, the pharmacy tech provided the man with a prescription for the anti-psychotic Lamotrigine instead. After taking 14 pills of the unprescribed medication, the man started to suffer the signs of kidney failure. He was eventually hospitalized and now requires daily dialysis.

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Earlier this month, the mother of a four-year-old epileptic girl went to fill her daughter’s prescription and was given the medication. According to a local news source covering the incident, the young girl takes two prescriptions for her condition, one of which is Clobazam and anti-epileptic. The girl’s doctor prescribed she take 10 mg of medication that contains five ml of the active drug. However, the pharmacy provided the girl’s mother with a medication that only contains 2.5 ml per 10 mg dose. The result was that the girl was only getting half of her required medication.

Cough SyrupTen days after the prescription was picked up, the girl had her first seizure. Since then, she has been unable to sleep through the night and has had several subsequent seizures. The mother told reporters that the pharmacy not only provided the wrong medication but also placed their own label on the manufacturer’s label, making the error harder to detect. It was not until a doctor at the hospital asked to see the bottle that the error was discovered.

In an interview with reporters, the girl’s mother explained that she “can forgive the initial mistake, but everything has to be seconded and signed off, and I can’t forgive whoever seconded it as they clearly didn’t do their job.”

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Prescriptions errors can occur in a number of ways. Perhaps the most commonly seen prescription error, however, is when a pharmacist provides one patient’s properly filled prescription to another patient. The patient who receives the incorrect medication risks having an adverse reaction to the unprescribed pills and also risks an exacerbation of their current condition, due to not receiving their prescribed medication.

Blister PackPrescription errors can often be prevented by a patient’s vigilance. However, the burden of ensuring the safe dispensing of medication should not lie with the patient. Indeed, the law allows for patients who have been injured as a result of a pharmacist’s mistake to seek compensation for their injuries through a personal injury lawsuit.

Many lawsuits brought against allegedly negligent pharmacists are defended in a similar manner. Specifically, the pharmacist will argue that the patient’s injuries were not caused by the pharmacist’s mistake. Since the burden rests with the patient to prove their case, this tactic can work for many pharmacists. However, an experienced personal injury attorney can assist pharmacy error victims by seeking out reliable and credible medical experts to explain to the judge or jury whether the ingestion of a foreign medication may have caused a new illness or disease or exacerbated an existing one.

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In October of last year, the parents of a young boy who suffers from a serious kidney condition discovered that the medication they had been giving their son on a daily basis was not the correct medication that had been prescribed by the boy’s doctor. According to a recent article discussing the family’s fight for justice, the pharmacy where the alleged error occurred is denying liability for the mistake, claiming that the prescription was properly filled.

White PillsAccording the article, the seven-month old boy was diagnosed with a serious kidney disorder at birth. Since then, he has had to undergo two surgeries and is required to take daily medication. After his second surgery, his mother filled her son’s prescription at a local pharmacy and gave her son the medication as directed.

When the mother went to the same pharmacy to refill the prescription, she noticed that the medication she was provided looked different from what she had been giving her son for the past month. Thinking that the pharmacist made an error in filling the refill, the mother brought the pills back to the pharmacy. However, the pharmacist told her that the refill was filled correctly, meaning that the initial prescription may not have been correct.

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Prescription medications are often dangerous drugs that are subject to government regulation, due to the potential harm they can cause when taken in a manner inconsistent with their therapeutic use. While the majority of pharmacy errors do not result in serious patient injuries, the reality is that there are a significant number of errors each year that do result in serious injuries or death. Often, the pharmacists responsible for these errors are subject to professional sanctions as a result of the error. However, these sanctions often seem insignificant compared to the injury or loss suffered by the victims of pharmacists’ mistakes.

Assorted PillsLast year, an elderly woman died as a result of taking five times the prescribed dose of an immuno-suppressant medication. According to a local news report covering the tragic death, the woman was provided the medication by a local pharmacy. Evidently, the prescription was initially incorrectly filled by a new technician. The supervising pharmacist caught the error and directed the technician to fix it. However, the technician failed to correct the mistake, and the pharmacist never double-checked the technician’s work.

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The results of a recently published study emphasize the crucial role that registered nurses (RNs) play in maintaining accuracy in dispensing medications to patients receiving inpatient services at a hospital. The recently performed study discusses the most common medications that are subject to error, as well as the rates of harm to patients that occur as a result of errors made by RNs. Costly errors appear to encourage doctors, hospitals, insurance companies, and the medical industry as a whole to issue guidelines in the hope of preventing errors. However, whatever harm these errors cause to the medical professionals who make them, the harm caused to innocent patients is significantly worse.

Blood Pressure CuffThe Study Confirms the High Rates of Inpatient Errors Committed by RNs

An article in an industry news source (login required) discusses the recent study mentioned above. The study found that the majority of medication errors occurred in the medical-surgical units of the hospitals where they were conducted, followed by the intensive care units and intermediate care units.

Anticoagulant drugs were the most common type of medication to be associated with a medication error, and 10% of the total errors ultimately resulted in harm to a patient. Although 10% sounds like a low number, that still adds up to hundreds of thousands of patients each year who receive some type of medication error and thousands who suffer harm as a result.

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