Pharmacy Error Injury Lawyer Blog

Four-Year-Old Boy Consumes Dangerous Dose of Antipsychotic Drugs for Several Months Due to Pharmacy Error

November 11, 2016 | Lebowitz & Mzhen

Many pharmacy errors result in the wrong dose of the prescribed medication being given to a patient by mistake, or the dosage instructions being printed incorrectly on the bottle. Thus, even when taking their medicines as directed, some patients are receiving significantly more (or less) medication than their doctor prescribed. A recently published article from a local news source discusses a case in which a pharmacy accidentally dispensed 10 times the prescribed amount of an antipsychotic medication to a young boy, who took the drug for several months before the error was noticed.

Boy Receives Prescription for 0.3 mg of Risperidone to Treat Behavioral Issues

According to the report, the boy and his mother visited a psychiatrist for treatment of psychological and behavioral problems. The doctor prescribed the antipsychotic medication Risperidone to the boy with instructions to consume 0.3 mg of the drug per dose. For several months, the pharmacy failed to see the decimal point and dispensed medication with instructions for the boy to consume three mg for each dose.

For months, the boy was taking intoxicating and dangerous levels of the drug. His mother visited several doctors, trying to determine what was wrong. Eventually, doctors noticed that the boy was receiving 10 times the amount he was prescribed, and the mother visited the pharmacy for answers.

Compounded Prescriptions May Present an Increased Risk of Pharmacy Errors

November 1, 2016 | Lebowitz & Mzhen

Most people who are prescribed a medication by a physician are prescribed a ready-made form of that medication, whether it be a pill, liquid, powder, or cream. However, sometimes a need arises for a physician to prescribe a very specific dose or form of a medication based on a patient’s individual needs. This is called a compounded medication.

Compounded medications require that a pharmacist mix together certain ingredients and essentially create the exact dose and form of a medication that is tailored to a patient’s needs. In many cases, compounded medications are required by the elderly or the very young. While compounded pharmaceuticals are necessary for some patients, there is a chance that the pharmacist creating the medication makes an error, resulting in the wrong medication or wrong dose being delivered to the patient.

Eight-Year-Old Boy Dies Due to Error in Compounded Medication

Earlier this year, a young Canadian boy died in his sleep after his mother provided him with a compounded medication created by a local pharmacist. According to a local news source reporting on the tragic error, the young boy suffered from an REM sleep disorder that required he take tryptophan. However, since the boy had difficulty taking the tryptophan pills, his mother had a special liquid medication compounded by the pharmacist. The compounded medication worked fine for 18 months.

High-Alert Drugs Pose a Heightened Risk to Patients, Yet Many Hospitals Fail to Identify Them

October 24, 2016 | Lebowitz & Mzhen

The Institute for Safe Medication Practices (ISMP) creates an evolving list of high-alert medications that, while they are not necessarily more likely to be involved in an error, are especially dangerous if they are accidentally given to a patient. However, according to one industry news report, despite the availability of this list, many hospitals across the country do not have a readily accessible high-alert drug list or fail to take appropriate measures to ensure hospital staff is aware of the list.

The report notes that some medications are more commonly associated with pharmacy errors. For example, medications with sound-alike names or medications that physically resemble other medications are more likely to be involved in an error. Thus, the report suggests that hospitals create hospital-specific lists of medications that may be at a higher risk of being involved in an error, due to specific factors in play at a particular hospital. For example, if the physical location of two drugs near each other has resulted in numerous errors, hospitals should add both medications to a high-alert drug list and take additional precautions so that these medications are not inadvertently mixed up in the future.

The report also explains that remedial measures taken by some hospitals are not effective in reducing pharmacy errors. For example, relying on staff training without further follow-up does not have a significant impact on error rates. Similarly ineffective measures are high-alert lists placed on pharmacy bins, since these are often overlooked by busy staff members.

Even Minor Medication Dosing Errors Seriously Affect Children

October 17, 2016 | Lebowitz & Mzhen

Prescription medications are powerful drugs that can have major adverse effects on everyone, especially children. These medications are available only with a doctor’s recommendation because they may have serious interactions with other medications, may present a high risk of overdose, or may require very specific instructions regarding how to take the medication. In children, even the smallest mistake can result in a serious injury or even death.

While many medication errors involving children take place at home when a parent gives their child medicine, the ultimate responsibility for the error may not lie with the parent. In fact, the way that many children’s medications are dosed makes it very difficult for parents to make the necessary conversions. In a recent report discussing pharmacy errors that affect children, it is noted that most children’s medication has one set of instructions for administration with an oral syringe and another for administration in teaspoons, leaving parents with the job of converting one into the other.

In fact, a recent study involving 2,000 children under eight years old and their caretakers found that 84% of the caretakers made some mistake with the administration of the child’s medicine. Most of these mistakes involved doses calling for measurement by teaspoon or measuring cups. Currently, there is a push by the Food and Drug Administration to standardize all doses in children’s medication, using milliliters. However, until then, it is recommended that extra precautions be taken to ensure that anyone providing liquid medication to a child understand exactly what the intended dose is.

Medical Mistakes Are the Third-Leading Cause of Death; Many Involve Pharmacy Errors

October 12, 2016 | Lebowitz & Mzhen

Many people are unaware, but medical mistakes are the third-leading cause of death in the United States, causing roughly 365,000 deaths per year. The category of medical mistakes is a broad category, including medical malpractice, diagnostic errors, surgical errors, and pharmacy errors.

Pharmacy errors occur when a pharmacist provides a patient with the wrong dose of a prescribed medication, the wrong directions on how to take a prescribed medication, or the wrong medication altogether. These errors may occur in the hospital setting or in a retail pharmacy, but errors occurring in the in-patient setting are even more frightening and surprising because the medication is actually delivered by a doctor or nurse. One would expect that this extra layer of interaction would result in most pharmacy errors being discovered before a medication is delivered to a patient, but that is not necessarily the case.

In a recent article discussing medical mistakes generally, as well as what can be done to prevent them, the writer mentions several precautions that can be taken to decrease the frequency of in-patient pharmacy errors. The first suggestion is to have pharmacists make rounds to see all patients in the hospital along with the doctors and nurses. The author explains that while doctors are in charge of a patient’s overall care plan, a pharmacist is a much-needed consultant when it comes to any potential interactions medications may have with one another. In fact, a recent study cited by the article notes that hospitals that have implemented this plan have seen a 94% reduction of serious pharmacy errors.

Pharmacist’s Error Results in Seven-Year-Old Boy Receiving Medication Ten Times Stronger than Prescribed

October 3, 2016 | Lebowitz & Mzhen

Recently, a New Zealand boy was admitted to the hospital three times after he was provided a prescription that was 10 times stronger than prescribed by his physician. According to a local news report covering the error and the subsequent investigation, the boy suffers from cerebral palsy and is prescribed Baclofen, a muscle relaxer, to help him control his symptoms.

Evidently, the prescription was phoned in by the boy’s physician and picked up by his mother. She gave him the medication as directed, and as a result she had to take her son to the hospital three times with increased seizures, shortness of breath, and deep breathing. It was not until the third visit to the hospital that it was discovered that the reason for her son’s exacerbated symptoms was the dispensing error.

An investigation was initiated by a government oversight group to find out how this type of error could occur. The investigators discovered that there were two pharmacists on duty that day: a filling pharmacist and a checking pharmacist. According to the inspector, the performance of both pharmacists fell short of the duty they owed the child. The investigator explained that “maintaining a logical, safe and disciplined dispensing procedure, including assessing the efficacy and safety of medicine, are fundamental aspects of pharmacy practice.”

Court Holds Pharmacy Has a Duty to Preserve Evidence of an Error

September 26, 2016 | Lebowitz & Mzhen

Earlier this month, a court in Nevada heard a case involving an interesting legal issue that has recently come up in courts across the nation. In the case, Burton v. Walgreen, the issue was whether a pharmacy had a duty to preserve evidence of an error made by one of the pharmacists. The court determined that whenever a patient returns medication to a pharmacy that was given to him in error, the pharmacy does have a duty to preserve it.

The Facts of the Case

According to a summary of the case, the patient was prescribed Valsartan, which is a blood pressure medication. He filled the prescription at a local Walgreen’s pharmacy, and when he got home, he began taking the medication as instructed. After taking about five doses, the patient’s wife noticed that there were two different kinds of pills in the vial that her husband was provided. The patient’s wife then took the medication back to the pharmacy, where the pharmacist confirmed that the patient had been given unprescribed lithium pills in addition to his Valsartan.

After documenting the error, the pharmacist quarantined and destroyed the medication, pursuant to the company’s written policy. In a lawsuit later filed against the pharmacy, the patient claimed that the pharmacy had engaged in spoliation of evidence. Spoliation of evidence is the destruction or significant alteration of evidence by someone who knows or should know that the evidence will be used as evidence in an upcoming court case. A court can impose sanctions against a party for spoliation of evidence.

Name Mix-Ups Are One of the Most Common Types of Pharmacy Errors

September 19, 2016 | Lebowitz & Mzhen

Pharmacists are human, and like all other humans they are susceptible to making mistakes. The range of pharmacy errors is vast, from incorrect medications to improper dosing instructions, but the effects are always the same. The patient is put in grave danger of either not receiving their prescribed medication or ingesting a potentially harmful, unprescribed substance. In any event, despite the fact that most pharmacy errors are committed by well-intentioned pharmacists, when a patient suffers serious harm as a result of an error, a personal injury lawsuit may be an appropriate way for the patient to receive compensation for all they have been put through.

Just as there are many types of pharmacy errors, there are also many causes. One of the most common causes of in- and out-patient pharmacy errors is a pharmacist mixing up similarly named medications. In fact, a recent article in one industry news source discusses how two similarly named drugs, Venofer and Vfend, were recently the subject of a potentially serious pharmacy error.

Evidently, the pharmacist who made the error had filled a prescription for Venofer 200 mg earlier in the day. Once complete, the pharmacist placed the prescription in the “complete” basket and moved on to other projects. Later that day, the pharmacist came across another prescription, this time for Vfend. Having just filled a prescription for Venofer, the pharmacist misread the label and grabbed Venofer instead of Vfend. Both drugs were in a 200-mg dose, adding to the confusion.

Hospital Implements New Safety Procedures to Reduce Pharmacy Errors

September 12, 2016 | Lebowitz & Mzhen

In order to reduce pharmacy errors, a hospital in Japan has adopted quality control procedures developed and used by Toyota, according to a recent article. The new procedures are intended to improve workflow among the hospital’s 30 pharmacists, who work in staggered shifts among racks and racks of prescription medications.

Prior to adopting Toyota’s safety measures, the hospital was known to have committed more than 10 pharmacy errors per month. After studying and implementing the new procedures, the hospital has reduced pharmacy errors by more than 50 percent.

Pharmacy errors are a worldwide problem, including in the United States. Common hospital pharmacy errors include giving patients the wrong dose of a medication, giving them the wrong medication altogether, or unintentionally giving them another patient’s medication.

Recent Study Estimates In-patient Medication Errors Cost the U.S. Health Care System $16.4 Billion Annually

September 5, 2016 | Lebowitz & Mzhen

Medical errors account for a huge number of serious injuries and deaths across the United States each year. In fact, according to a recent report, medical errors are the third-most common cause of death in the United States. Included in the term “medical errors” are mistakes made by doctors, such as misdiagnoses, surgical errors, and medication errors.

No matter where in the health care system a serious error occurs, the medical professional responsible for the error may be held liable through a personal injury lawsuit. By virtue of caring for patients, doctors and pharmacists assume a responsibility to provide a certain level of care, as measured by the professional standard in that specific geographic area. When a physician’s or pharmacist’s performance falls short of this duty, they could be found liable for medical malpractice or general negligence, depending on the allegations.

According to a recent study conducted by the Institute of Medicine of the National Academies, approximately 1.5 million people are affected each year by medication errors. While many of these errors occur in the out-patient setting of retail pharmacies, a significant number of medication errors occur in the in-patient setting as well. In fact, according to a recent study conducted by the Network for Excellence in Health Innovation, preventable in-patient medication errors cost the U.S. health care system approximately $16.4 billion each year. This figure includes amounts for the treatment of preventable illnesses and diseases that were caused by medication errors, as well as the cost of hospital readmission. Importantly, this figure does not include the cost incurred from the many successful negligence and medical malpractice lawsuits that are settled or resolved each year.