Pharmacy Error Injury Lawyer Blog

ISMP Reports of New Medication Errors Leading to Drug Omissions

March 1, 2010 | Lebowitz & Mzhen

A recent article from the Institute for Safe Medication Practices (ISMP) that our Maryland-based medication error attorneys have been reading reported that the order management scanning system (OMSS) technology that was created to improve the efficiency and safety of the drug ordering process for doctors and pharmacies, is now experiencing error-prone problems that are leading to medication errors, drug omissions and missed drug therapy in patients.

OMSS is a technology that was created to capture a digital image of a handwritten or printed prescription order and send it to the pharmacy—eliminating faxing, the use of a courier, or the use of pneumatic tubes to transport the information to the pharmacist. The idea behind OMSS was to accelerate the time the prescription hit the pharmacy, speed up the prescription filling process, with electronic filling, easy retrieval of scanned orders, and reduce the risk of transcription errors because the order can be magnified. Unfortunately, according to the article, these OMSS benefits are null and void if the pharmacy never receives the prescription orders.

The problem that is reportedly occurring is that multiple pages of orders are being pulled through the scanner at the same time, and the scanner is only reading a single page at a time—a problem that has also plagued pharmacies with faxing or copying orders in the past. When this problem occurs, staff may not be aware that only one page was scanned, and the pharmacist may not be aware that they should have received multiple pages of orders. As a result, drug omissions can take place, leading to medication mistakes or missed drug therapy.

In one documented case, a physician wrote three pages of admission orders for a patient suffering from lung cancer, as well as difficile colitis and fever. When the orders were scanned with OMSS, the pharmacy only received two pages of the orders, because one page was not pulled through. Neither the nurse who administered the medication the physician, nor the pharmacist noticed the prescription error and omission. The drugs prescribed on the missing page were seizure medications. By the forth day of receiving only a fraction of the medication, the patient was exhibiting behavior that lead the emergency response team to determine that the patient was having a seizure. The patient was transferred to critical care unit, where the doctor figured out the pharmacy mistake, and although the patient required intubation, he ultimately experienced a full recovery.

New Legislation for the Safe Disposal of Nursing Home Resident Drugs

February 26, 2010 | Lebowitz & Mzhen

In a recent news story that our Maryland Medication Error Attorneys have been following, state legislators across the country have proposed bills that are aiming for the disposal of unused or expired medicine at nursing homes, for resident health and safety and the protection of the environment

According to ABC News, Maryland, Maine, Minnesota, Colorado, and Washington have all proposed new legislation that is trying to address the issue of dealing with excess and expired prescription medicine from nursing homes that end up in landfills and water sources every year, or if accidentally accessed by residents or other people, can cause serious harm or personal injury.

The Associated Press did a study in 2009, and reported that at least 250 million pounds of pharmaceuticals and contaminated medication packaging are generated in medical facilities every year. Some states are working on bills that would give nursing homes a choice to donate unused medication to charities in other countries. Other states are trying to send the unused medication back to the prescription drug manufacturers, with ‘take back’ programs, returning the responsibility back to the pharmaceutical company for disposal.

When a prescription is written for a resident in a nursing home, the pills aren’t reportedly dispensed in the same way that they are in a pharmacy. When the prescription is ordered for a nursing home resident, the pharmaceutical companies allegedly ship out 30-day supply cards, with each pill nestled in a small bubble pocket so nurses can easily pop the pill out of the card. If the patient has a bad reaction to the medication, if the patient passes away, or there is a medication mistake with the prescription, the medicine is most likely thrown out.

Incentives to Using Electronic Health Records in Physician Practices

February 24, 2010 | Lebowitz & Mzhen

Recently, our Maryland Medical Mistake Lawyers wrote about the use of electronic health records in hospitals and doctors’ offices, and how computerized health records have the potential to improve the health care of patients, and reduce the risk of medical errors and personal injury.

In the blog, our pharmacy error attorneys wrote about how President Barack Obama’s economic stimulus included over $19 billion for health information technology, and has given many hospitals great incentive to add their own funds and invest in adopting electronic records to improve the quality, safety, and efficiency of health and medical care.

One example of this comes from an article in the New England Journal of Medicine from last month, where the Long Island North Shore Hospital System in New York stated publicly that it will pay an up to $40,000 incentive offer to each doctor who agrees go electronic with health records—paying 50 percent of the total cost to doctors who install the Electronic Health Record that will communicate directly with the hospital, and will pay 85 percent of the total cost if the doctor shares quality care data.

The payment would reportedly add to the $44,000 physician incentive offer, where the American Recovery and Reinvestment Act of 2009 gave authority to Medicare to compensate health care professionals eligible for the payment, who used electronic health records in a meaningful way. According to the article, ‘meaningful use” is not yet clear in definition, but the overall aim is to transform the health care delivery system by using electronic records, to improve communication, efficiency, and quality care and reduce the risk of personal injury through medical mistakes or pharmacy error.

Reducing Medical Error by Implementing Electronic Health Records

February 23, 2010 | Lebowitz & Mzhen

In a recent post, our Maryland Medical Error Attorneys discussed how computerized health records have been used by the Veterans Health Administration for the past decade, with great reported success. These electronic records have reportedly improved the health care and well being of nearly eight million veterans, by storing information electronically about the prescriptions, studies, laboratory tests, consultations, doctor’s notes and any reports about the patient in any Veterans Affairs hospital—reducing the potential for medical errors or personal injury.

Yesterday The New York Times published an article discussing the reported benefits of electronic records, and how President Obama’s economic stimulus that included $19.2 billion for health information technology, has given many hospitals incentive to invest in creating and using electronic records to improve the efficiency, quality, and safety of medical care. The goal according to the article is to integrate the various systems across the country with various hospitals and medical groups so medical records can be shared on a common platform within the different systems.

According to the article, the benefits of electronic health records are:

• If the doctor has immediate access to a patient’s record, it could reduce medical errors and personal injury within the hospital setting due to drug complications, pharmacy errors, drug allergies, or potential drug interactions, as well as drug recalls.

• Electronic records can eliminate duplicate tests, from M.R.I.’s to blood tests. If a patient is seeing multiple doctors, a new doctor can easily access their test results electronically within the same system, which can prove to be valuable in a life-threatening situation. If a test needs to be repeated, the doctor will have access to the results of the last test to compare.

Walmart Pharmacy Misfill—Teenager’s Acne Prescription Wrongly Filled with Viagra

February 17, 2010 | Lebowitz & Mzhen

In recent news that our Washington D.C. Pharmacy Misfill Attorneys have been following, a young woman in Florida recently experienced a serious medication error when she filled her prescription for doxycycline, a medication for acne, and received a bottle of Viagra instead.

According the news story, after picking up her prescription acne medication at the Walmart pharmacy, she didn’t realize that was mistakenly given Viagra capsules because the capsules were reportedly very similar to the medication she took in both shape, color, and size. She proceeded to take the Viagra without realizing the mistake, and claims to have suffered with health related conditions. It wasn’t until her family discovered the other patient label on the bottom of the bottle underneath her name that clearly indicated that the medication was Viagra, and intended for another patient.

The family of the teenager confronted the pharmacy at Walmart, and claimed that the college student has suffered many physical problems as a result of the pharmacy misfill and medication mistake. She claimed that after taking Viagra, she experienced serious health complications, including a racing heartbeat, extreme bodily temperature changes, anxiety and bouts of dizziness.
According to the U.S. Food and Drug Administration (FDA), 1.3 million people are injured every year in this country from medication errors, with at least one death reported every day. The National Coordinating Council for Medication Error Reporting and Prevention, (NCCMERP), reports that injury from medication error is an huge problem and health risk for the public, and needs to receive far more public attention. Medication mistakes can happen anytime in the pharmacy process, from prescribing, distribution, dispensing, administering or monitoring—often times resulting in personal injury.

Hospitals Fined by CDPH for Alleged Medication Mistakes

February 1, 2010 | Lebowitz & Mzhen

In recent article that our Maryland-based Medical Mistake Attorneys have been following, The California Department of Public Health (CDPH) has fined 13 hospitals in California $650,000 for 16 medical mistakes that have caused serious patient injury, harm, or even wrongful death in 2008 and 2009.

In one hospital pharmacy error in Oakland, California, a 90-year old emergency room patient at Kaiser Foundation Hospital, received a variety of blood pressure and stomach ulcer medications that were meant for another patient. The emergency room staff did not double check the medication orders sent from the pharmacy, and the patient went into severe respiratory distress after receiving the potassium chloride by mistake.

A rapid response team was sent in and the patient was reportedly breathing four to six breaths per minute with a fluctuating blood pressure. The man was intubated and put on a ventilator for breathing. Further testing proved that the patient lost brain function from the medication error. A physician interviewed by the California Health investigators claimed that he could not rule out the possibility that the medication mistake caused a severe change in the patient’s health.

In another case, at California Hospital Medical Center in Los Angeles, a patient was incorrectly given the drug Methotrexate, or chemotherapy, as a treatment for ectopic pregnancy—even though the patient was not in fact pregnant. Over the following week, the patient reportedly developed immune suppression, renal function decline, severe leukopenia and neutropenia, and oral, skin and esophageal ulcerations due to the medication error. The investigators reported that using chemotherapeutic medication on a patient who was not pregnant subjected the patient to serious health complications, physical harm, and injury.

Jury Orders Rite Aid to Pay $2.5 Million for Pharmacy Misfill

January 28, 2010 | Lebowitz & Mzhen

As Maryland Pharmacy Misfill Attorneys, we have been following the recent verdict in which $2.5 million in damages were awarded to a Montgomery, Alabama woman and her husband, who claimed to be victims of a Rite Aid Pharmacy prescription misfill.

According to the lawsuit filed in 2008, Reva Tosh received a prescription for a pain medication on November 11, 2006. When Tosh dropped off the prescription to the Rite Aid pharmacy two days later, the pharmacist misfilled the order with the steroid dexamethasone—a steroid with severe side effects often prescribed during cancer treatments.

Rite Aid Pharmacy allegedly gave Tosh more than seven times the regular dosage of the steroids for a period of 28 days, and she claimed to have developed a disorder of the adrenal glands called Cushing’s Syndrome, that caused her to suffer physical ailments, personal injury, and mental disorders, that confined her to a wheelchair.

During the trial, the the central issue was whether Tosh’s injuries were caused by the pharmacy misfill, or due to her preexisting illness of rheumatoid arthritis.

Reva Tosh was awarded $2 million in damages by the jury, and her husband Gerald Tosh received $500,000 for the his loss of her companionship.

Lawsuit Accuses Hospital of Medication Mistake and Wrongful Death

January 27, 2010 | Lebowitz & Mzhen

In a recent lawsuit that our Maryland Pharmacy Mistake Lawyers have been following, a hospital is being sued for dispensing an overdose of pain medicine to a 68-year old woman, which allegedly led to her wrongful death.

Mable Mosley was taken to the Brandon Regional Hospital last year complaining of neck and shoulder pain. She checked into the hospital on a Saturday, and within a few days stopped breathing. Mosley was put on life support, and died days later.

Mosley’s husband is suing the hospital, the hospital owners, and seven individual pharmacists in the case, claming medication negligence and wrongful death—that his wife was given enough pain medicine to end her life.

The drug in question that Mosley received is called Duragesic, a patch containing large concentrations of opioid fentanyl, a potent narcotic approved in 1990 by the FDA for use in patients that have become opioid-tolerant from using another strong narcotic pain medication for a week or longer.

Opioids are chemicals that are commonly prescribed because of their pain relieving properties. Opioids work by attaching to opioid receptors, or proteins, found in the brain, spinal cord and gastrointestinal tract. When the drugs attach to the opioid receptors, they can block out the body’s perception of pain.

FDA Pressures Johnson & Johnson for Broad Recall of OTC Drugs

January 25, 2010 | Lebowitz & Mzhen

Johnson & Johnson (J&J) has recently recalled certain lots of Tylenol, Rolaids, Benadryl and Motrin, after consulting with the U.S. Food and Drug Administration (FDA). McNeil Consumer Healthcare, the J&J subsidiary that sells the drugs, is voluntarily recalling the lots of the Over-The-Counter (OTC) products, in an effort to maintain the health and safety of the consumer and to prevent OTC medication errors.

The company has recalled these drugs based on consumer complaints of an unusual, moldy, musty smell that reportedly caused nausea, vomiting, diarrhea and gastrointestinal pain. The smell was found to be caused by trace amounts of the chemical 2, 4, 6-tribromoanisole (TBA)—a chemical often applied to wood pallets that are used in the transportation and storage of the materials used for product packaging.

The FDA has criticized J&J for not reacting quickly enough to customer complaints, and for failing to fix the problem, a problem that has been familiar to J&J. Customers have reportedly been complaining since 2008 about their pills having a mildew-like odor. In December of 2009, Tylenol Arthritis Pain medication was also recalled related this same issue.

According to the FDA, J&J and McNeil did not conduct a quick and comprehensive investigation into the problem, and failed to provide high quality products to consumers—responsibly protecting them from personal injury or illness. Many consumer complaints were received as early as 2008 and 2009, and the test results indicating TBA contamination were not shared with the FDA until after an inspection.

Dangerous Error-Prone Prescription Abbreviations

January 20, 2010 | Lebowitz & Mzhen

As Maryland Pharmacy Error Attorneys, we have been following a recent report by The Institute for Safe Medication Practices (ISMP) about the danger of error-prone abbreviations and when it comes to writing a prescription—the fact that some shortcuts don’t save time, and can result in pharmacy error or injury.

According to the ISMP Error Alert article, nearly everyone in the healthcare industry uses shortcuts, like abbreviations and symbols, in an effort to save time when handwriting specifics for the prescription—including phrases, units of measure and words. Some shortcuts can in the end can be very time consuming, as they need to be checked and verified for accuracy on the receiving end. These verifications could also reportedly cause a greater chance for medication error than if the prescription was written out without abbreviations or symbols. The article claims that it is important to prevent future misunderstandings now, instead of waiting until medical abbreviations, dose designations or symbols lead to a patient injury.

The article lists a few common error-prone abbreviations, symbols and dosage misunderstandings that take more time for the pharmacist to check, and could cause medication mistakes:

• Some abbreviations that indicate the frequency of when to take the drug, can be difficult to understand, and can lead to error. In one prescription for “Penicillin VK 500 mg Q1D X 7D,” the physician accidentally typed “Q1D” (once a day) instead of “QID” (four times a day). The pharmacist realized the mistake, and that the patient was supposed to be taking the penicillin four times a day for seven days (7D). Another example of frequent error comes in the abbreviation for “D” (days), where it can also be mistaken for “doses.”