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A recent news report details just how troublesome prescription errors by pharmacies can be, resulting in sanctions. In the state of Iowa, state regulators recently penalized a drugstore accused of destroying relevant paperwork after dispensing the incorrect medication to a customer. According to the Iowa Board of Pharmacy, in 2020 the Walgreen store dispensed the incorrect strength of insulin pens and the incorrect test strips to a patient. During an investigation the Walgreens was unable to provide some of the original documentation related to the prescription. It was determined that the prescription records had been destroyed, which is in violation of Iowa regulations. As a result, the Board of Pharmacy issued a warning and imposed a $1,500 civil penalty, in addition to requiring the store to provide two hours of educational training on patient safety to all permanent pharmacists and technicians on staff. In addition to the one Walgreens being sanctioned, at least one other pharmacy in Iowa was sanctioned for dispensing a prescription with incorrect directions which led to a customer taking a higher dosage than was prescribed. In one case, a pharmacist’s license was placed on probation after a criminal conviction.

How Does Maryland Protect Pharmacy Patients?

Pharmacy boards are administrative agencies created by state governments “to protect the health, welfare, and safety of the public through the regulation of pharmacy practice.” In large part, these entities are responsible for preventing pharmacy errors. State pharmacy boards have taken important steps to regulate and discipline pharmacies and drug laws. For example, in the state of Maryland, the Maryland Board of Pharmacy has a mission of “protect[ing] Maryland consumers and to promote quality healthcare in the field of pharmacy through licensing pharmacists and registering pharmacy technicians, issuing permits to pharmacies and distributors, setting pharmacy practice standards and through developing and enforcing regulations and legislation, resolving complaints, and educating the public.” Guidance by the Office of Inspector General in the United States Department of Health and Human Services outlines that state pharmacy boards should review the outcomes of their disciplinary process and evaluate whether they are affording the public the maximum protection.

While state pharmacy boards play an important role in regulating and disciplining pharmacies and helping protect patients, in some prescription error incidents, victims or the loved ones of victims may consider filing a lawsuit to recover damages. These suits can be complex as you navigate the laws and court system, but connecting with an experienced attorney who can help you navigate your case can be beneficial.

When medication dispensing errors happen, they can cause serious side effects and life-altering issues for patients, and in some cases, these errors can lead to death. According to the National Institute of Health (NIH), each year in the United States, 7,000 to 9,000 people die as a result of a medication error, and hundreds of thousands of other patients experience but often do not report an adverse reaction. Medication errors can cause a lack of trust in the healthcare system generally and in healthcare providers. In addition, these errors have financial costs as well, with the NIH reporting that medication-associated errors exceed $40 billion each year.

According to a recent news report, a medication dispensing error in D.C. almost cost a 74-year-old woman her life. The patient had been recently released from the hospital and went to a rehab facility to recover from a blood clot. However, within weeks, the patient began complaining about swelling in her throat, prompting her family to look at what prescriptions the facility had given her. Her family members realized that the facility had dispensed the wrong medication, giving her drugs with someone else’s name on them. To make matters worse, the patient’s eldest daughter realized that the facility had given her a drug that her mother was severely allergic to. The patient was raced to the nearest emergency room just in time, as her throat was nearly swollen shut. She was put into a medically induced coma for more than a week.

Why Do Medication Dispensing Errors Happen?

Medication dispensing errors can occur for a variety of reasons, including human errors or issues with protocols that fail to prevent mistakes from happening. These reasons may include illegible handwriting, confusion over similarly named drugs or packaging, or errors involving dosing units, amongst many other reasons. In addition, if protocols and systems are not properly and effectively put in place to require that medical providers have a backup system to detect mistakes, then this can also lead to more pharmacy errors that could have possibly been avoided.

A recent news report reveals information regarding the pharmacist and technician shortage and its impact on access to healthcare. For example, in the state of South Dakota, pharmacies have been randomly reducing hours and closing the pharmacy, which has led to patients being unable to get the prescriptions they need. These pharmacy issues are happening across the country. The stress from the pandemic on the healthcare industry can be attributed to the pharmacy technician shortage and impending pharmacist shortage. Some pharmacists have no choice but to work through their lunch hour despite the pharmacy being closed to patients.

Additionally, there may be underserved areas of a state where there are only a couple of pharmacies or even one pharmacy in the entire county. For patients who depend on their local pharmacy for their medications, this can be a difficult predicament to be in if the local pharmacy can no longer remain open. In addition to pharmacists playing a pivotal role in helping patients, pharmacy technicians are essential. Technicians not only help pharmacists with administrative tasks but also assist with locating, dispensing, packing, and labeling prescriptions. In some cases, pharmacists may be paid to cover a technician shift due to the shortage. Some workers in the field believe that increasing the pay of technicians, who are now expected to do a wide array of tasks, may help with creating more interest in the position.

Pharmacy schools have also seen a drop in enrollment, which may stem from the pandemic playing a role. In addition, the pandemic causes a number of early retirements in the field. Pharmacists were essential employees, still needed even during the height of the pandemic. There’s been a decline in the number of applications that pharmacy locations are receiving, whereas, in the past, one opening would garner many interested applicants. As a result, some stores have offered sign-on bonuses for pharmacists to help recruit.

Medication error has been a leading cause of harm for patients, and an expensive cost for healthcare providers. In a digital age, some healthcare providers have implemented digital solutions to medication errors, but these digital solutions can cause doctors to receive too many alerts that lack specificity and that also cause alert fatigue for doctors. However, when science and technology combine to create a unified and efficient approach for drug administration and managing clinical decisions, it can be life-altering. A Healthcare IT News article details the importance of hospitals integrating precision medicine with digital maturity models. The digital maturity models can help technology advances that support clinical decisions. This can help prevent errors and increase efficiency, which thus can save lives and costs for hospitals. Giving users access to a single information source in a unified approach can help with drug administration and minimize alerts.

What Is a Digital Maturity Model?

Some examples of digital maturity models include from Wolters Kluwer, which built Medi-Span Clinical APIs drug data solution and expert services which helps ensure that accurate information is available at key moments rather than reported after the event, and also ensures the precision of alerts. Another example is the National Chen Kung University Hospital in Taiwan, which has used Medi-Span Clinical APIs to overcome challenges faced by pharmacists, including the challenge of the amount of time it takes to update a medication database. Medi-Span’s databases are updated regularly with best practice evidence and recommendations. Clinical APIs are for healthcare professionals only, and there are certain regulations that guide their use in various locations.

The hospital’s data shows that since implementing Medi-Span, the number of alerts has been reduced by 21% and the talerts have captured severe potential Adverse Drug Events. This resulted in saving approximately $39,200 in U.S. dollars a year, and also saved an estimated 266 bed days a year. Technology advances can allow for solutions that help prevent medication errors and help ensure that patients receive the best and safest care possible. When these errors occur but can be avoided by digital maturity, it is up to hospitals to implement unified approaches to avoid such costs.

Feeding tubes can be an essential tool used to administer medicine to patients who need it. People who have difficulty swallowing or difficulty feeding may need enteral feeding tubes. Although an essential tool, more must be done to prevent errors that occur when preparing and administering medications via enteral feeding tubes. Enteral feeding tubes allow liquid food to enter the stomach or intestine through a tube. Enteral feeding tube errors occur for a variety of reasons, including gaps in training, incorrect tube or route size, improper preparation, and utilization of the wrong administration technique.

What Are the Causes of Feeding Tube Mistakes?

In some instances, practitioners have not received the proper training associated with prescribing, verifying, prepping, and administering specific medications through feeding tubes. Knowledge may be passed down from practitioners, but there may lack a standard policy for doing so to ensure that there are no gaps in knowledge. Additionally, there are errors that occur if a prescriber selects an incorrect route, such as selecting the oral route of administration for a patient who actually requires medication via an enteral feeding tube. Improper preparation can result in adverse reactions for the patient and the practitioner. In these scenarios, if a practitioner fails to use proper personal protective equipment (PPE) and crushes a hazardous medication, this can result in toxicity or reduced efficacy of the medication. Additionally, error also occurs if the wrong administration technique is used. This includes mixing multiple medications together to give to a patient at once, failing to flush the tube before and after medication administration, and mixing medications with enteral feedings.

In order to prevent these errors, practitioners should screen for enteral feeding tube restrictions, create policies that are located in a central location for reference, and should ensure that practitioners are properly educated on how to safely prepare and administer medication. In addition, because patients will often follow the same procedure to prepare and administer medications at home, it is important to educate patients about safe practices. If you have reason to suspect that a loved one has suffered injuries due to error that occurred during the administration of medication via an enteral feeding tube, contact an experienced and skilled medical malpractice attorney today to discuss your options.

When it comes to our prescriptions, we count on pharmacies to get it right. Instructions scribbled by doctors on notepads or hurriedly said by nurses and office staff while we check our calendars for follow up appointments or scrutinize our bills are hardly reliable. Instead, checking and double-checking pill bottles or printed pharmacy instructions before consuming prescription medication is often the safeguard patients use to ensure they’re not over or under consuming their prescribed drugs. When these instructions are wrong, the results can be catastrophic.

What Are the Potential Harms of a Medicine Dosing Error?

According to a recent report, a prescription for alirocumab, a drug to prevent cardiovascular events, was marked with erroneous directions. The pharmacy instructed the patient to inject “1 mg,” or one milligram, under the skin every 2 weeks. But the actual instructions were supposed to be injection of one milliliter. The instructed dosage would have been confusing and impossible to measure for a patient. While this error was fortunately realized by the patient due to the difficulty in measuring one milligram, other such errors—like transcribing a number incorrectly—could result in over or under-consumption of medications, which can lead to overdose or prolonged illness.

In this case, the error occurred because the verification by two pharmacists failed to catch the mistake. Some pharmacies do not have processes for typing directions, even though these medications should often be administered in a standardized way. Doctors provide varying instructions, and pharmacies often follow the doctors’ instructions verbatim or close to it, without verifying the units and dosage against standards for the medication. The prescription in question would have also been easier to understand had the pharmacist instructed the patient to inject one entire pen, rather than 1 milliliter or milligram, as the pen was designed to hold one dose. Pharmacies can also employ more checks to ensure patients understand how to use medications, like asking patients to repeat instructions back and confirm dosage.

After a long period of lockdown, demand for COVID vaccines and boosters has been high. At times, the demand has exceeded both the supply of vaccines and pharmacies’ capacity to administer them. Unfortunately, when a pharmacy accepts a high volume of patients without increasing its capacity and hiring more staff, it can result in errors and mix-ups. These errors in vaccine administration have the potential to be fatal.

As a recent news article reported, a woman received the incorrect COVID vaccine booster at a Walgreens pharmacy in Rutland, Vermont. The woman received the vaccine after making an appointment for the “newest, most updated” COVID booster. Two days after her appointment, she received a call from the pharmacy informing her they had mistakenly administered an older version of the booster. The pharmacy employee told her she was still protected from COVID; however, the booster would not protect her from the newest strain. Luckily, the woman did not suffer any medical issues from the mix-up. However, given the potential for a more dire mistake, she filed a complaint with Walgreens’ corporate offices. After doing so, she claims she received an indication that other people had also received the wrong vaccine, though Walgreens denies that it happened to anyone else at the Rutland location.

Notably, the Vermont Office of Professional Regulation filed a complaint in June 2022 seeking to revoke or otherwise discipline the licenses of 32 Walgreens stores in the state, including the Rutland pharmacy. In fact, in its complaint, the Office reported that unsafe conditions at the pharmacies have increased the risk of prescription errors, vaccine administration mistakes, and the risk of harm to patients. Allegedly, Walgreens’s vaccine scheduling site had allowed such high volumes of appointments that staff could not keep up with the demand. According to the complaint, these issues resulted in the pharmacy’s inability to safely administer vaccines.

Patients seeking medical care have certain standards and expectations for what they will receive when getting treatment. When those standards are not met, the consequences can be dire. For patients whose lives are on the line, one small mistake from a doctor, nurse, or pharmacist can have an enormous impact.

Recently, a woman picked up what she thought was cancer medication from her local pharmacy. She took the prescribed pills for two months before realizing that she had actually received anti-cholesterol medication from the pharmacy instead of the medicine she intended to be taking. The woman’s doctor had prescribed her a drug called exemestane, but the pharmacist had failed to check the medication bottle and had given her something called ezetimibe instead.

Apparently, the pharmacists providing the medication failed to properly dispense the prescription. The pharmacy was supposed to have a three-step process for ensuring that each patient’s medicine was what they were expecting to receive: a check when the medicine was selected from the shelf, a second check when the dispensing label was put on the container, and a third check when the prescription was given to the patient.

After almost two years since COVID-19 vaccines become available, there are still concerns regarding avoidable administration errors that result from labeling and communication errors. When we walk into a doctor’s office to receive vaccines, we trust that we will receive the correct vaccination. But when administration errors occur for various reasons, it is important that these errors are accurately reported and that steps are taken to prevent these administration errors from happening again.

According to a recent news report, one current problem involves the labeling of the Moderna vials for the primary series for ages 6 to 11 years of age, which are still labeled as “for booster doses only.” Despite the label, these are not used for booster doses. In addition, there are two different Moderna vaccine vials that have a similar dark blue cap, which could result in an error if the vaccines are stored close together. The labeling includes the word “bivalent”, which may be more difficult to see on the Pfizer booster dose for ages 12 years and up, while compared to the Moderna label which may feature the word “bivalent” more clearly on the label. The word “bivalent” is essential to distinguish between the monovalent vaccine.

According to an interview involving the president of the Institute for Safe Medication Practices (ISMP), which was shared by Pharmacy Practice News, ISMP has received messages via Linkedin, phone, and email regarding how the labels appear to be so similar and regarding the difficulty of seeing the word “bivalent.”

People that regularly take prescription medicine or have received prescription medication in a hospital or clinic setting can appreciate the vital importance of best practices when it comes to receiving medicine. Whether it is at the pharmacy or in the hospital, it is essential to be aware of safety measures that could make a major difference in the care you receive. Every patient deserves peace of mind when it comes to their medications, and to live free of the consequences of medical and pharmaceutical malpractice.

How Common Are Medication Mistakes?

Incorrect or erroneous distribution or application of medications is surprisingly present in the United States. In fact, some sources cite a rate of one in five Americans experiencing a medical error while receiving health treatment. Unfortunately, Maryland is no exception to this trend, and Maryland residents should be aware of emerging best practices in the face of the increased computerization of pharmacies and hospital medication cabinets.

Emerging Best Practices to Reduce Harm

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