Pharmacy Error Injury Lawyer Blog

Death from Medication Error Leads to Prevention Awareness

November 10, 2009 | Lebowitz & Mzhen

As Maryland Medication Error Injury Attorneys, we have recently read data from the U.S. Food and Drug Administration (FDA) stating that in the United States, 1.3 million people are injured by medication errors every year, with at least one death reported every day.

According to the National Coordinating Council for Medication Error Reporting and Prevention, (NCCMERP), injury from medication error is an urgent, a widespread public problem, that needs to receive far more public attention. The NCCMERP estimates that 98,000 people die annually from medical errors that occur in hospitals—an amount that is greater than deaths from motor vehicle accidents, breast cancer, AIDS, even workplace injuries. Medication error can happen at any point, and result in injury—from communication, distribution, prescribing, dispensing, administering or monitoring.

A medication error is defined by the the NCCMERP as any event that is preventable, and may cause medication misusage or patient harm while the medication is being controlled by the health care professional, consumer or patient. Medication errors can happen in professional practices and during procedures, as well as in the systems of prescribing, ordering, the labeling of a product, packaging, dispensing, education, monitoring, usage, and naming conventions.

The FDA states that common causes of medication error stem from poor communication between doctor, pharmacist, and patient, with unclear product names or suffixes, medical abbreviations or handwriting, poor techniques or procedures, or a lack of understanding of directions for patient usage. Job stress or lack of training or knowledge can also lead or contribute to pharmacy error injury or misfills.

Veterans Hospital Paves the Way for Computerized Records

October 30, 2009 | Lebowitz & Mzhen

In a post from earlier this year, our attorneys at Lebowitz & Mzhen Personal Injury Lawyers discussed how computerized health records would help Maryland pharmacists and doctors to eliminate Maryland medication mistakes.

According to a recent article in the Wall Street Journal, on how to digitize the health-care industry, Veterans hospitals have proven to have paved the way——showing doctors and pharmacists important lessons on how to effectively make the digital transformation.

The U.S. Department of Veterans Affairs digitized their records years ago, with great results. Independent studies show that the VA outperformed the private sector and Medicare on preventative services and chronic care. VA officials have claimed that the digital technology has helped cut down on patient hospitalizations and has helped patients live longer.

The VA’s digital records system has been a blessing to patients, allowing doctors and nurses at more than 1,400 facilities to share the medical history of the patients—avoiding the unnecessary repetition of costly tests. As well as storing patient data, the system gives screening warnings and keeps an eye on patient levels, like blood pressure and weight—all safeguards for improved quality care.

In a digitized record for a 59-year old Maryland patient at the VA medical center, all of his health problems were listed, like diabetes and hypertension, as well as all of his data since he has been a patient at the center. The screen showed a list of all current medications, including insulin, the drug Furosemide for heart failure, and Oxycodone, the pain medication. The patient’s doctor can reorder a drug through the system, sent directly to the pharmacy—eliminating medication mistakes and pharmacy misfills. If the doctor orders a new prescription that conflicts with a drug the patient is already taking, there is a warning in the system.

Medication Error Injury Prevention—Study Recommends Knowing Your Pharmacist

October 26, 2009 | Lebowitz & Mzhen

A recent American Pharmacists Association (APhA) survey, that our Maryland Pharmacy Error Injury Attorneys have been following, revealed that 1.5 million people are injured by medication-related errors every year. The APhA commissioned the consumer survey, led by Harris Interactive, to investigate how consumers interact with their pharmacists, and how building relationships with pharmacists can avoid patient error and reduce medication mistakes and pharmacy misfills.

The APhA always recommends that people carry an updated list of their current prescription medications, over-the-counter (OTC) drugs, herbal supplements and vitamins. The list should include the name of the medications, the dosage, as well as the conditions that the medications treat. Any patient allergies should also be included in the list.

The study reports that while a large percentage of Americans have an up-to-date list of medications, only 28% of consumers actually carry the list with them at all times—an act that could prevent personal injury and medication mistakes, by providing emergency personnel and pharmacists with lifesaving information regarding drug names, proper dosing, allergy information, and drug interactions and side effects.

According to Kristen Binaso, pharmacist and national APhA spokesperson, until electronic medical records are used as the standard in sharing patient information in the health care industry, consumers should protect themselves by keeping a current medication list with them at all times, to show the doctor and pharmacist—to avoid the risk of improper dosing, medication duplication, pharmacy misfill, and harmful drug side effects and interactions. In a recent post, our Maryland Mistake Attorneys further discussed how these electronic health records will help pharmacists and doctors to eliminate medication errors.

Next to doctors, pharmacists are the second most trusted health care providers and trained medication experts, yet the survey found that 77% of consumers do not know their pharmacists names, and only 40% of consumers have asked their pharmacists valuable questions about their medication needs.

Cardiac Medication Dosing Errors Reported Most Commonly With Infants

October 23, 2009 | Lebowitz & Mzhen

As Maryland Medication Mistake Attorneys, we have been following a recent article from Cardiology Today, revealing that cardiac medication mistakes are reported most commonly with infants—in community hospitals, university hospitals, and pharmacies.

The results of a study showed that diuretics and antihypertensive agents are the most commonly reported drugs that are improperly dosed with infants—frequently prescribed by doctors for pediatric patients with heart disease. According to the article, these drugs have the potential for more widespread use because of neonatal care advances, and the increasing incidence of metabolic syndrome and childhood obesity.

Diuretics and antihypertensive agents are considered by many to be safe, because of their frequent use by doctors, but according to the research, it would be much more beneficial for the physicians, clinicians and pharmacists to have accurate information on the assessments of harm rates, and the groups of infant patients who are at particular risk—to prevent serious medical mistake errors and injury with children.

The most harmful error reports came from reported dosing error of the heart condition drugs: nesiritide, calcium channel blockers, milrinone, digozin, and antiarrhythmic agents.

According to the results from voluntary CV medication error reports that were submitted to a medication error database from the years 2003 and 2004, 50% of the total errors reported occurred in children younger than 1 year of age, and 90% of the error reports occurred in infants younger than 6 months of age.

In the 1,424 causes reported, the most frequent causes of medication error or pharmacy misfills were:

• Human error
• Improper dosing
• Missed or double doses
• Misunderstanding of drug orders
• Mathematical errors which include dilutional errors

ISMP Medication Error Cases and Prevention Checklist

October 9, 2009 | Lebowitz & Mzhen

In a prior post from this week concerning pharmacy error injury, our Maryland Medication Error Attorneys at Lebowitz & Mzhen Personal Injury Lawyers discussed a recent study published by the Institute of Medication Practices (ISMP), and the ongoing problem with drug naming standards in extended release medications.

In this study, the ISMP revealed a series of cases reported to the institute, in which drug name suffix medication mistakes have frequently occurred. This study showed specific case examples in order to establish clearer naming conventions in the industry, and improve comprehensive pharmacist and patient awareness—to prevent pharmacy error injury and misfills in the future.

The ISMP study reported these specific medication mistake cases:

• Physicians often prescribe extended release products without the correct suffix, or with a suffix that does not exist for that particular product.

• In an analysis of 402 prescribing errors published by Medscape Pharmacists, the most common type of error in the study (280 cases, 69.7%) was failure to specify the controlled release formulation.

• The ISMP received reports of cases in which pharmacists dispensed Metadate ER instead of Metadate CD—two different extended release forms of methylphenidate-UCB, a stimulant medicine commonly used to treat ADHD. In one case, a prescription for Metadate CD 20 mg was misfiled at a pharmacy, where the staff dispensed Metadate ER 20 mg.

• Some products have multiple suffixes for different formulations of the same drug. Diltiazem products for example (calcium channel blockers) are used to slow the heart rate and normalize the heart rhythm in hypertension and arrhythmia. The many suffixes for Diltiazem include SR, CD, XR, XT, and LA.

• Electronic prescribing can also lead to medication errors on behalf of the prescriber. In one case, a prescriber electronically selected metroprolol tartrate instead of metoprolol succinate because of choosing incorrectly on his PDA.

According to this report, pharmacists, practitioners, and patients should take extra care when reviewing the different formulations and medication names, especially if the medication is available in more than one dosage form.

The ISMP recommends the following medication error prevention checklist:

Patient Safety Alert: ISMP Reports Medication Error with Drug Name Suffixes

October 6, 2009 | Lebowitz & Mzhen

As Maryland Medication Error Attorneys, we have been following a recent study published by the Institute of Safe Medication Practices (ISMP), about the lack of prescription drug naming standards in extended release medications that lead to pharmacy error injury.

According to the study, although extended release drug formulations provide multiple benefits for many patients, the titles used for many medications are often confusing, and can cause patient error when the same drug is presented with several different oral dosage forms in the suffix.

Extended release drug formulations play an important role in maintaining consistent prescription therapies, by preventing the need for patients to remember to repeat dosages—delivering a steady dose of the medication throughout a specific period of time. The difficulty with many of these medications comes in the name. According to the study, drug manufacturers add suffixes or modifiers to already well-known medication names, to keep awareness of the brand, yet differentiate between the immediate-release counterparts. For example: Wellbutrin SR is a sustained release anti-depressant, whereas Wellbutrin XL is the extended-release version. Same name, different release rate.

Maryland Law Encourages Maryland Doctors to Computerize Patient Records

May 27, 2009 | Lebowitz & Mzhen

In prior posts concerning Maryland medication mistakes, the attorneys at Lebowitz & Mzhen Personal Injury Lawyers have discussed how computerized health records help doctors and pharmacists eliminate medication errors.

Today, Governor Martin O’Malley, signed a bill that is designed to increase the speed with which Maryland doctors implement electronic patient records. The new law hopes to reduce the high costs that doctors must pay to implement electronic patient records systems by requiring private insurance companies to give physicians financial incentives to implement electronic patient records. Under the law, after a doctor implements a computerized records system, insurance companies may offer the doctor increased reimbursements for procedures they perform, a lump sum payment, or some other monetary advance. Additionally, under the new law, the state will fine physicians who have not adopted a computerized records system by 2015.

Since 2003, Maryland has been on the cutting edge of the movement towards computerized patient records. In that year, The Montgomery County Health Information Exchange Collaborative began a pilot program that linked community hospitals, the county’s health department, and area health clinics. The link allowed participating health care providers to easily access patient records.

The program developers believed that their medical information network would have the greatest impact on the county’s poorer citizens and those without health insurance. These individuals generally receive care in a number of different locations, and often times, the facilities do not share vital patient information. The link allowed the facilities to share patient information and reduce the risk of medication errors.

Maryland medication mistake attorneys will review the impact this law has on patient safety, and the state’s progress towards completely computerized patient records.

Patient Safety Alert: Medication Mistakes with Injected Medicines Are Frequent

April 28, 2009 | Lebowitz & Mzhen

According to researchers, the results of a recent international study demonstrate that patients receiving injected medicines are at a higher risk of medication mistakes. Researchers determined that oral or written miscommunication were the root cause of 24% of all errors, and that health care workers confused drug names in 18% of the cases.

Researchers in the study observed patients in Intensive Care Units in 27 countries, including two in the United States, and found that 20% of patients experienced at least one error and 14% experienced more than one injected medication mistake. Fifteen errors caused either permanent injury or death of the patient involved.

Overall, researchers concluded that patients with more serious illness were at a higher risk for injuries caused by these mistakes. Maryland medication mistake attorneys believe that the results of this research demonstrate the importance of patients having a family member act as their advocate during an extended hospital stay. In addition to questioning doctors, the advocate should pay particular attention to the medications prescribed to the patient and attempt to make sure that health care workers administer the medications at the proper times and in proper dosages.

Government Program Hopes to Reduce Medication Mistakes Across the Country

April 27, 2009 | Lebowitz & Mzhen

In prior posts, Maryland medication mistake attorneys have asked our readers to question their doctors before taking prescription medications. Proactive patients are better able to notice potential medication mistakes before they occur and are less likely to suffer injuries.

The Agency for Healthcare Research and Quality (“AHRQ”), a part of the U.S. Department of Health & Human Services, has noted the substantial impact medication mistakes have on patients and the country as a whole. On itswebsite, the AHRQ quotes a report from the Institute of Medicine (“IOM”) which found that medication mistakes kill from 44,000 to 98,000 people each year. The report also indicated that medical mistakes cost the country approximately $17 billion each year in increased health care costs.

In order to help reduce medication mistakes, the AHRQ has developed a national ad campaign to encourage Americans to take a more active role in their health care by asking critical questions of their doctors, nurses, and pharmacists. The program drives home the point that Americans typically ask more questions of a cellular phone salesperson than they do of their physicians. The campaign’s website provides a top ten list of critical questions patients should ask their health care providers during appointments. Additionally, the website also has a “Question Builder” that allows readers to develop their own personalized list of questions.

Maryland Judge Refuses to Apply Cap on $3 Million Jury Award in Medical Mistake Case

April 21, 2009 | Lebowitz & Mzhen

In a prior post, the attorneys at Lebowitz & Mzhen Personal Injury Lawyers have discussed Maryland’s statutory cap on non-economic damages and how this limitation impacts Maryland injury victims. A recent court decision, however, has drawn attention to Maryland’s limit on non-economic damages in certain medical malpractice cases.

In Semsker v. Lockshin, a jury found a Silver Spring dermatologist and his practice group liable for the death of Richard Semsker. In 2004, Dr. Lockshin’s office treated Semsker for boils on his back and conducted a full body examination for other possible skin issues. During the examination, Lockshin’s associate, Michael Albert, M.D., noted two cysts and an abnormal mole on Semsker’s lower back. Dr. Albert removed the boil and two cysts. However, the dermatologist did not excise the abnormal mole and recommended monitoring only. Over the next two years, the abnormal mole became cancerous and the cancer spread throughout Semsker’s body, and he died at the age of 47, in October 2007. The family later sued the Dr. Albert, and his practice group.

The jury awarded Semsker’s wife and children over $5.8 million in damages, including $3 million in compensation for the family’s mental anguish. Under the state’s limitation on non-economic damages, the $3 million award for pain and suffering would have been reduced to $812,500. However, Judge John W. Deblius III of Montgomery County refused to apply the cap to the Semskers’ damages award. Judge Deblius ruled that the cap did not apply to medical malpractice cases in which the parties did not first attempt arbitration.