Pharmacy Error Injury Lawyer Blog

Safety of Electronic Medical Records Questioned After Pharmacy Error Leads to Death of Infant

August 3, 2011 | Lebowitz & Mzhen

A recent Chicago Tribune article, that our Baltimore pharmacy misfill injury attorneys have been following, looks closely at electronic medical record safety, after a tragic medication error occurred, stemming from a computer mistake made at the Chicago-area Advocate Lutheran General Hospital, that caused the death of a newborn infant.

According to the article, Genesis Burkett, an infant born 16-weeks premature, was given a fatal overdose of sodium chloride last year, receiving over 60 times the dosage ordered by the physician. The hospital pharmacy error was reportedly made after a technician from the hospital pharmacy misread and inaccurately typed the doctor’s handwritten prescription orders into a hospital computer—a common source of pharmacy misfills and errors, as attorneys have discussed recently in a Baltimore pharmacy error injury blog.

The data entry mistake then caused a pharmacy misfill, as the automated machine prepared an intravenous solution containing a lethal overdose of sodium chloride that caused the infant’s heart to stop. Advocate Health Care’s chief medical officer, Dr. Lee Sacks stated that the pharmacy error could have been prevented by the automated alerts on the IV compounding machine, but at the time that the customized bag was prepared for the infant, the alerts were not activated and connected to the main pharmacy information systems at the hospital. The family’s attorney reportedly blamed the pharmacy error and wrongful death on a mislabeled IV bag.

After the medication error led to the infant’s tragic death, Advocate has since added electronic alerts to the IV compounders and initiated other medication safety measures to prevent this kind of pharmacy error from happening in the future.

Risperdal Recalled by Manufacturer Due to Drug Contamination

July 29, 2011 | Lebowitz & Mzhen

Our Talbot County, Maryland pharmacy error injury lawyer blog recently discussed a series of recalls drug maker Johnson & Johnson made last year, in an effort to maintain the health and safety of consumers—after complaints of an unusual smell causing nausea, vomiting, diarrhea and gastrointestinal pain were reported, due to trace amounts of 2, 4, and 6-tribomoanisole (TBA), a chemical used to preserve wood necessary in the construction of pallets used for transportation and shipping of the product packaging materials.

In related news, Ortho-McNeil-Janssen Pharmaceutical, the drug manufactures of Risperdal (risperidone), an antipsychotic drug used for the treatment of schizophrenia, bipolar disorder, and irritability associated with autistic disorder in adolescents and children, recently voluntarily recalled 16,000 bottles of the brand name drug and 24,000 bottles of the generic drug—also because of an unusual odor.

The Risperdal drug manufacturers found that the unusual smell was also caused by trace amounts of TBA, used to preserve wood pallets for the transportation and storage of product materials. While not considered to be toxic, a small group of patients have reported gastrointestinal symptoms when taking products with this offensive odor. The drug maker claims that the presence of TBA has not caused any reported serious adverse events, but the company has instituted a series of actions to reduce the potential of TBA contamination in the future, to avoid personal injury or harm to any consumers.

This is the second medication error warning surrounding Risperdal this year. Last month our attorneys discussed another warning involving Risperdal in a Baltimore pharmacy error injury blog, issued by the U.S. Food and Drug Administration, discussing potentially dangerous medication errors associated with Risperdal and Requip, a drug used for the treatment of Parkinson’s disease and Restless Legs Syndrome, with 226 reports of patients receiving the incorrect medication.

Report Warns Consumers to Take Precautions With Drug Labels and Instructions

July 25, 2011 | Lebowitz & Mzhen

In a previous Baltimore medication error injury blog post, our attorneys discussed a recent investigation by Consumer Reports Health that found evidence of inconsistency among prescription drug labels for warfarin, a blood thinner. The report found that important safety warnings and medication guides that are required by the federal government in order to prevent medication errors, were often omitted or left out of patient’s warfarin prescriptions.

As our Maryland pharmacy mistake lawyer blog has reported previously, every year, according to research by the Institute of Medicine, there are 1.5 million preventable medication error injuries, one third of which take place outside of hospitals, where consumers must make their own decisions about following medication instructions. Consumer Reports Health suggests that these medication errors happen because consumers are confused by the material that is included with prescriptions, and that they rely heavily on the medication bottle label—a problem if there are omissions or inconsistencies with the drug label.

The report found the following discrepancies:

• Four out of five pharmacies neglected to provide the medication guides that are required by the FDA for certain drugs, including warfarin.
• All of the pharmacies provided their own materials for the patients, but these conflicted with the guides for warfarin approved by the FDA. The FDA recommended that patients abstain from alcohol while taking the drug, while two pharmacies warned patients that they should just limit or avoid alcohol usage.

Consumer Reports Health Investigation Finds Drug Label Warning Inconsistency

July 18, 2011 | Lebowitz & Mzhen

A recent investigation that our Hartford County pharmacy error injury attorneys have been following found evidence that drug labels are often missing the important safety warnings necessary to prevent medication error and that many pharmacies neglect to include the proper medication guides that are required by the U.S. Food and Drug Administration (FDA).

The investigation was performed by Consumer Reports Heath, by filling warfarin prescriptions at five different New York drugstores. Warfarin is a blood thinner used for stroke prevention that is one of the most frequently prescribed drugs in the country.

The results found that four out of the five pharmacies neglected to provide the FDA-approved medication instructions that are required for specific drugs, warfarin included. Although the pharmacies reportedly provided their own medication materials, they were different from the warfarin drug information approved by the FDA, in that the warnings about the usage of alcohol were different. Warfarin can reportedly cause life-threatening internal bleeding if used incorrectly, and is the second in line for drugs that cause emergency room visits in hospitals across the country, due to medication error.

Another goal in the investigation was to see how certain drug labels, consumer drug information sheets, and medication warning stickers differed in each pharmacy. Although a certain degree of variation was expected, as various drugstore chains use different software to print labels and drug instructions, the findings raised significant concern.

Medication Errors Linked to Death of Patient in Nursing Home

July 8, 2011 | Lebowitz & Mzhen

In a recent Baltimore pharmacy error injury blog, our attorneys discussed a pharmacy misfill and medication error that lead to a 94-year-old nursing home resident’s wrongful death in New York, after she received the incorrect medication for nearly twenty days as a result of a pharmacy misfill.

In a related news report, a patient in a nursing home, also in the State of New York, has recently died, after medication errors allegedly led to her wrongful death.

The patient reportedly entered the Lake Ridge Care Center on the 10th of January in 2010, due to congestive heart failure and low potassium. Her doctor reportedly ordered that the she receive three doses (two-tablets) of potassium every day. According to the New York State investigation, the staff of the home failed to properly administer twenty-six of the medication doses to the patient over a period of eight days.

On January 23, 2011, the patient was reportedly sent to the hospital emergency room, where she suffered a severely abnormal heart rhythm and died the same day, from cardiac arrest. Her potassium levels were found to be extremely low, due to medication errors that led her to miss her prescribed potassium doses to help blood pump through the heart.

New Study Finds Electronic Medication Error Rates Consistent with Handwritten Prescriptions

July 1, 2011 | Lebowitz & Mzhen

In recent news that our Pharmacy error injury attorneys have been following, a new study from the Journal of the American Medical Informatics Association found that prescriptions sent electronically to pharmacies by doctors are almost as likely to have errors as the prescription medication orders handwritten by doctors.

The study examined 3,850 electronic prescriptions that a commercial pharmacy retain chain received over a period of four weeks in 2008. Out of the 3,850 e-prescriptions studied, researches found that 12%, almost 500, contained a total of 466 prescribing errors.

The researchers noted that their findings on e-prescribing error rates are consistent with their earlier study and research for error rates on handwritten prescriptions. Out of the 466 electronic prescribing errors discovered, only one-third of them could have caused patient harm or personal injury.

According to Bloomberg, the results undermine the safety benefits expected from e-prescribing, especially as the federal government paid over $158.3 million to doctors and hospitals in the beginning of 2011 to encourage doctors to switch over to electronic health records, as a way to reduce healthcare costs and eliminate medical and medication errors. The report found that although many providers are rapidly adopting electronic health records and e-prescribing, many of the expected benefits of the electronic computerized prescribing will not take effect if the electronic prescribing applications are not able to catch medication errors, or in fact cause medication errors.

FDA Warns of Confusion between Risperdal and Requip, Leading to Medication Error

June 27, 2011 | Lebowitz & Mzhen

The Food and Drug Administration recently issued a warning about the potentially dangerous medication errors occurring with the drugs Risperdal (risperidone) and Requip (ropinrole)—with 226 reports of patients accidentally receiving the wrong drug, causing sickness and at least one death.

Risperdal (risperidone) is an antipsychotic used for the treatment of schizophrenia, autism side effects and bipolar disorder, and is reportedly being confused with Requip (ropinirole), a drug used for the treatment of Parkinson’s disease and Restless Legs Syndrome, that acts in place of dopamine.

According to the Food and Drug Administration report, the medication errors are happening as a result of the drug name similarity as well as the similarity in generic drug labels and packaging, with overlapping drug characteristics such as the drug strengths, and dosing intervals. Other errors have reportedly stemmed from illegible handwriting on prescriptions.

Patients who were victims of the medication errors have reportedly experienced confusion, tiredness, hallucinations, and an altered or changed mental status, among others health problems.

The FDA warns patients who are taking the generic versions of Requip or Risperdal to notice the name and appearance of their medication, to know exactly why they are taking the drug, and to ask any questions and to report any difference in medication appearance to their pharmacists—to avoid pharmacy misfills or medication errors.

Walgreens Pharmacy Misfill Causes Dosing Error

June 21, 2011 | Lebowitz & Mzhen

In a recent pharmacy misfill news story that our Maryland pharmacy error injury lawyers have been following, a pharmacy customer has received an apology from a local Walgreens pharmacy, after receiving refills of a medication that contained a dosage that was ten times stronger than what the doctor had prescribed.

The pharmacy misfill reportedly took place repeatedly for around a year, where Larina Helsom took a 50mcg tablet twice a day instead of a 5mcg dose. The medication reportedly caused the Helsom to suffer from chest and esophageal spasms that were so painful she couldn’t talk or breathe. When they first started happening, Helsom thought that she was dying.

After months of taking the prescription misfill, Helsom reportedly went through several hospitalizations for the spasms, along with other prescribed medications to control the symptoms. Once the drug misfill was discovered, her doctor advised that Helsom stop taking the drug immediately.

The Arizona State Pharmacy Board is reportedly now investigating Walgreen’s pharmacy misfill, to decide whether negligence was a factor in the mistake. Last year, the pharmacy board reportedly received 131 complaints about pharmacies statewide. Walgreens claims that the prescription dose at issue was within the normal range of dosing for this drug.

Study Shows Transition to Electronic Medical Record Systems May Cause Potential Errors

June 15, 2011 | Lebowitz & Mzhen

According to a recent study published in the Journal of General Internal Medicine, although doctors and hospitals are in a mad dash to update to new electronic medical record systems (EMR)–after last year’s stimulus package promised a $27 million pay out to providers that meet the new EMR use–that transition can be risky and lead to an increase in certain types of medication errors in the months after the switch.

In the study, that our Hartford County, Maryland pharmacy error attorneys have been following, researchers found that although the change to a more streamlined system for entering prescription drug orders led to a general decrease in prescribing errors, other types of errors surfaced in the first few months after the changes were made.

Researchers reportedly followed 17 doctors who switched to new EMR systems, and found that improvements were immediately found in prescribing errors, where abbreviations that have a high potential to cause patient injury or harm dropped significantly. But rates of other prescription errors, such as medication direction mistakes were higher three months after the EMR switch over, and some rates of errors were even higher after an entire year using the system.

Rainu Kaushal, the chief of the division of quality and medical informatics at New York-Presbyterian Hospital/Weill Cornell Medical College, and the author of the study, claims that although the overall drop in prescribing errors is good, the results of the study show that there is a need for constant reassessments of the new systems—especially to prevent prescribing and medication errors in the future.

FDA Tips for Administering OTC Medication to Children—to Reduce Medication Error Injury

June 6, 2011 | Lebowitz & Mzhen

In a previous Washington D.C. medication error injury lawyer blog, we covered the recent guidelines announced by the U.S. Food and Drug Administration (FDA) aimed to prevent medication errors and overdoses with children’s over-the-counter (OTC) medications.

According to the FDA, accidental medication errors and overdoses in young children are a common health problem, but a problem that is entirely preventable. The new guidelines are aimed to reduce frequent medication administration errors that happen as a result of confusing label instructions, inconsistency with the drug measuring devices, and confusion over the exact units of medication measurement—to prevent harm or injury.

Along with the new medication error prevention guidelines, the FDA also outlined tips for parents and caregivers, to reduce administration error when giving medicine to a child or infant.

According to the FDA, always:

• Know the active ingredients in the medicine that you are giving to your child.
• Read and follow the drug facts label on all medicines that are OTC.
• Use the tools for dosage administration that come with the medicine. Never use tools from other medication.
• Be aware of the difference between a teaspoon and a tablespoon.
• Know your child’s weight exactly.
• Check the medicine three times.
• Make sure to give the right medicine in the exact amount that is directed.
• Ask your doctor, nurse or pharmacist to make sure which medicines can be used at the same time.
• Store your medicines in a safe place that is out of reach for children.
• Make sure to use caps on all medicines that are child-resistant.