Pharmacy Error Injury Lawyer Blog

Steps for Preventing Prescription Errors in Pharmacies

December 29, 2009 | Lebowitz & Mzhen

In a related blog from yesterday, our Maryland Pharmacy Misfill Lawyers discussed a recent article from USA Today, where the step-by-step process of how a prescription is filled was followed in two pharmacies—to uncover how pharmacy mistakes are taking place, and how to prevent them in the future.

The article revealed how the possible errors are made and also discussed what steps pharmacies are making to try and prevent these errors, and reduce the number of pharmacy mistakes and patient injuries that could happen in the future.

Pharmacies are trying to prevent errors by:

• Encouraging improved communications between doctors and pharmacies.

• Encouraging doctors to write the prescriptions in full length, instead of using medical codes or abbreviations.

• Trying to transition from prescriptions that are handwritten to electronic prescribing—where a doctor sends the prescription directly from the doctors’ offices to the pharmacy computers.

• Computers are being used to aid the prescribing process, with more alerts for drug interactions, allergies, or patient’s illnesses.

• Other computer safety features include popup boxes when a technician enters or confuses a drug name with similarly named drug. After the popup appears, the technician has to initial the box to show he checked the drug.

Understanding the Prescription Drug’s Path through a Pharmacy can Reduce Error

December 28, 2009 | Lebowitz & Mzhen

In a recent study that our Maryland Pharmacy Error Attorneys have been following, USA Today investigated every step of a prescription’s path in a pharmacy—to uncover the potential for medication mistakes with each step of the filling process, that can lead to patient injury or wrongful death.

In the research, USA Today interviewed pharmacy experts and toured two pharmacies, a CVS and Walgreens, to study the six steps of the prescription filling process, and the potential errors that can happen along the way, as well as real cases that have caused actual injuries or death.

Step 1: Prescription received

When the customer drops off the prescription to the technician, or the doctor’s office calls in the prescription, errors can occur if a technician misunderstands a doctor’s handwriting, prescription codes and abbreviations or misunderstands the oral instructions over the phone. In one case, a doctor’s prescription for methadone read “sig 4 tablet BID for chronic pain,” which means “Please label (sig) this drug to say: take 4 tablets twice per day (BID) for chronic pain. The technician typed, “Take 4 tables by mouth as needed for chronic pain.” The patient allegedly died of an overdose of methadone.

Step 2: Prescription entry
A technician then scans the original prescription into the computer and manually enters the patient’s personal data, like name, address, date of birth and phone number, as well as drug information, strength, dosage instructions and quantity. If a technician incorrectly types the prescribed drug dosage, formulation or the patient’s medical condition, history or allergies into the computer, then serious errors can occur, including personal injury. Also if the wrong drug code is chosen in the computer system, it can be mistaken for a similarly named drug. In one instance, a pharmacy was asked to fill a prescription for compazine, an anti-nausea drug, (COM) and accidentally gave the patient a generic substitute for coumadin, a blood thinner (COU).

Pharmacy Mistake Leads to Wrongful Death—Rite Aid Faces Lawsuit

December 22, 2009 | Lebowitz & Mzhen

Our Maryland Pharmacy Error Injury Lawyers have been following the recent case filed last week on behalf of John Sheridan, a man who died after being prescribed the wrong dosage of a cancer medication.

According to the suit, Sheridan was prescribed Temodar, a powerful drug for brain tumors that was part of his treatment of cancer in September 2007. The prescription was allegedly written incorrectly, and Sheridan was wrongly prescribed 10 times the correct dosage—he reportedly took the medicine daily when it was only to be used every other week. Rite Aid Pharmacy allegedly dispensed the drug to Sheridan, without checking with Sheridan’s oncologist for a second opinion to clarify the prescription mistake.

The lawsuit accuses a Rite Aid pharmacy for contributing in the wrongful death of Sheridan, who reportedly had consumed toxic doses of the cancer medication. According to the Associated Press, the doctor who wrote the incorrect prescription has settled with Sheridan’s estate.

According to a 2006 report from the Institute of Medicine, at least 1.5 million Americans are injured by medication mistakes every year, and nearly 7,000 people die every year from medication errors annually.

Childrens’ Doses of Swine Flu Vaccine Recalled in Maryland

December 17, 2009 | Lebowitz & Mzhen

In Maryland news this week, our medical mistake lawyers have been following the recall announcement by Sanofi-Aventis, the vaccine manufacturer of 800,000 doses of H1N1 vaccine for children under the age of three. According to the Washington Post, the flu vaccine has lost potency after being shipped from the factory, and doses are being recalled in Maryland and nationwide.

The recall dosages are single-dose pre-filled syringes containing the vaccine specifically created for children ages 6 to 35 months. It is a voluntary, nationwide recall by Sanofi Pasteur.

During testing at the time of the vaccine’s manufacture, the doses contained 7.5 micrograms of antigen, the recommended dosage used to stimulate immunity in children. But later testing showed degradation of the vaccine, making it less potent than desired. This proved to be the case with four lots of the vaccine, totaling 800,000 doses.

According to the Centers for Disease Control Prevention (CDC), this recall is part of a routine quality assurance program and is non-safety related. Children who received the vaccine do not need to be re-immunized, but with future immunizations, children should be given the proper vaccination dosage. With children who have only received one vaccine dose, they should get the get their scheduled second dose.

QJM: How to Prevent Medication Errors and Injury with Balanced Prescribing

November 30, 2009 | Lebowitz & Mzhen

As Maryland Medication Mistake Attorneys we have recently read an article published in the QJM, the long-established leading general medical journal, on the topic of medication errors—giving an overview of what medication mistakes are, how they happen, and how to prevent them from happening in the future.

According to the article, published in August 2009, a medication error is a failure in the process of treatment that can lead to the harming or personal injury of a patient. Medication errors can often occur in:

• Prescribing faults: ineffective prescribing, irrational or inappropriate prescribing, under-prescribing and over-prescribing when deciding which treatment and dosage plan to take.

• Prescription writing: illegibility
• Formulation manufacturing: incorrect strength, misleading packaging
• Drug formulation dispensing: incorrect drug, formulation and label
• Administering the medicine: incorrect dosage, wrong directions for frequency, invalid duration of treatment
• Monitoring drug therapy treatment and drug treatment alteration when required

Medication errors can be classified, according to the article, by the use of psychological error classifications—knowledge-errors, rule-errors, action-errors, and memory-based errors. It is important to detect the medication mistakes, that can range from trivial to serious, and to create a working environment that is free of blame, and encourages the reporting of errors.

The article also recommends, “balanced prescribing” to avoid medication errors. In balanced prescribing, the mechanism of action of the drug should complement the pathophysiology of the disease—optimizing the balance of benefit to harm.

Walgreen’s Pharmacy Misfill—Child Given Heart Medication Instead of H1N1 Antiviral Drug

November 27, 2009 | Lebowitz & Mzhen

Our Pharmacy Misfill Attorneys in Maryland have been following the recent news of a dangerous medication mistake made by a Walgreen’s pharmacy, where a child was given heart medication instead of an antiviral drug to treat the H1N1 flu virus.

When Wilma O’Neill picked up the prescription for her daughter earlier this month, she expected to administer an antiviral medication to help her child’s swine flu symptoms. Over the next 24 hours, O’Neill gave her daughter two doses of the Walgreen’s prescription, and only stopped the medication after the drugstore called, claiming that there had been a pharmacy medication mistake, and someone had received the wrong prescription.

O’Neill brought the prescription back to the pharmacy, where they discovered that her daughter had been given the liquid pediatric medication Amiodarone by mistake—a drug used to treat irregular rapid heartbeats. According to Medline Plus, the U.S. National Library of Medicine on-line service, Amiodarone is used to treat and prevent life-threatening abnormal heart rhythms by relaxing overactive heart muscles, and is used only when other medications are not tolerated. The first few doses should reportedly be administered in a hospital setting, as the medication could cause fatal side effects. The child had been given two times the normal dosage of the actual heart medication, which could have resulted in pharmacy error injury.

O’Neill’s daughter was raced to the emergency room, and monitored carefully. Her EKG was initially normal, and then irregular a day later. O’Neill believes that had the mistake not been realized, the outcome could have been much worse, as her daughter was also very sick with the H1N1 virus.

Walgreen’s acknowledged the mistake and apologized for the error. The company didn’t disclose how the error was discovered, but claimed to have numerous safety checks in place in the drugstore to reduce the possibility of human error. In 2007, Walgreen’s was profiled in a the news program “20/20” for making prescription drug errors, after a child was mistakenly given an adult blood-pressure drug by the pharmacy. The child was rushed to the emergency room after weeks of taking the medicine with delirium symptoms and shaking limbs.

Alert for Public Safety—FDA Reports Medication Error with Tamiflu

November 18, 2009 | Lebowitz & Mzhen

The FDA has recently published a patient safety alert, reporting medication dosage errors associated with Tamiflu, (for oral suspension), the top doctor prescribed anti-viral flu medication, administered to both adults and children. Our Maryland Pharmacy Misfill Injury Attorneys have been following this prescriber and pharmacy alert report, and how it could effect patient safety in this current H1N1 influenza pandemic.

According to the agency alert, the FDA has received reports that the Tamiflu (oral suspension) dosing instructions for the patient do not match the dosing dispenser. U.S. health providers often write liquid medicine prescriptions in teaspoons or milliliters (mL), while the dosage of Tamiflu is in milligrams (mg). Prescribers and pharmacists have been warned that Tamiflu’s dosing dispenser included in the package has markings only in mg—30, 45, and 60.

The alert recommends that:

Dangerous Drug Abbreviations that Lead to Medical Injury

November 13, 2009 | Lebowitz & Mzhen

In the ongoing topic of medical error and injuries that our Maryland Medication Mistake Lawyers covered earlier this week in a previous blog, the National Coordinating Council for Medication Error Reporting and Prevention (NCCMERP) recommends that in order to help prevent medical error injury and death every year, it is important that the prescribers of medication avoid the use of dangerous abbreviations in prescriptions, including those for drug names and Latin directions for use.

The current NCCMERP list of dangerous abbreviations commonly made by prescibers include:

• Mistaking “µg” for “mg” or milligrams, resulting in an overdose

• “U” is mistaken for zero or a 4, which also results in an overdose. “U” is intended to mean “Units” but with poor handwriting, it can also be mistaken for “cc” or cubic centimeters.

• “Q.D.” means “every day” in Latin. The period after the “Q” is sometimes mistaken for an “I”—and the drug is given “QID” (four times daily), which results in an overdose.

• “T I W” means three times a week. This is often misinterpreted as “three times a day”
• “IU” means International Unit, and is often mistaken for “IV” or intravenous

• “AU, AS, AD” are the Latin abbreviations both ears, left ear and right ear. These are often misinterpreted as the Latin abbreviation “OU” (both eyes), “OS” (left eye), and “OD” (right eye)

The Council also recommends that in order to enhance the accuracy of prescription writing and communications, doctors, nursing and pharmacy staff should:

• Make sure all prescriptions are legible and include notes on medication purpose—like cough, or allergies—maintaining that the proper medication is dispensed.

• All prescription orders should be written in the metric system, except for orders that use standard units like vitamins or insulin. Units should also be written out, rather than abbreviated with “U”

• Medication orders should include the exact drug name, metric weight or concentration, dosage form, with strength and concentration expressed in metric amounts.

• The NCCMERP reports that numerous errors in drug strength and dosage have occurred with the use of decimals—due to the trailing zero (1.0 mg) or the lack of a leading zero (0.1 mg). A leading zero should always be used before a decimal, and trailing zeros should never be used.

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.