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Current news on prescription errors and pharmacy mistakes nationwide

Wrong Medication

• Checking Pictures of Medications Saves Patients from Pharmacy Errors
  Feb 04, 2012

  Two patients in Florida narrowly avoided prescription drug error lawsuits by checking the medication they received against a photo of the drug—and finding that the two weren’t a match.
  
  One patient was saved by the pharmacy’s method of labeling each drug with a description of the medication, including color, size, shape and numeric code printed on the pill.
  
  “I checked the tablets and discovered that the bottle contained the wrong medicine,” the patient reported. “The color and shape were right, but the tablets were stamped with the wrong code.”
  
  When the patient returned to the pharmacy to confirm the mistake, the pharmacist confirmed that he had been given the wrong pill; it was the correct medication, but the dosage was four times higher than his own prescription.
  
  Another pharmacy customer reported an incident that took place over a decade ago, but could have cost her son his life.
  
  The young man refilled his usual prescription for an anti-seizure medication and was taking it three times a day. He noticed a minor change in the pill, but didn’t think it was cause for alarm.
  
  A few days later, he told his mother he was feeling unwell. When she looked up the medication in the image section of a drug reference book, his mother found that he had been taking Lasix, a powerful diuretic, instead of his anticonvulsant medication.
  
  The man survived, but only because he was rushed to the emergency department and given an IV of potassium. “The doctor told me if my son had let this go another 24 hours, his heart would have stopped, and my son would have died,” the woman said.
  

• Medication Errors Run Rampant in Long-Term Care Facilities
  Jan 28, 2012

  A recent UK study found that one in every 15 hospital admissions of care home residents are due to medication errors, with the cost of hospital stays reaching nearly $2 billion per year.
  The study was the first large-scale program of its kind.  Researchers tracked all medications given to 345 elderly residents across thirteen UK care homes for three months.  The data showed that 90% of nursing home residents suffered medication errors at least once, and over half of residents were exposed to serious or harmful errors (such as giving a patient the wrong medication).
  Nearly 200,000 separate medication administrations were analyzed in an effort to track down the major causes of error.  The study revealed that residents received an average of nine different medications, exposing each patient to 206 medication administrations per month.  During the three-month study, each resident experienced 6 potential errors, with the most common being an attempt to give a medication at the wrong time.
  There are a few reasons why the error rate in care homes is so high.  Ala Szczepura, Professor of Health Services Research at Warwick Medical School, commented, “It is known that staff in care homes are administering, on average, seven different drugs to residents, and that medication rounds occupy approximately one-third of nursing time.”
  Another reason is the resident’s inability to take control of their own medical care, since approximately 37% of people suffering from dementia in the UK now live in residential care homes and cannot voice their concerns about their medications.  In these cases, automated systems may prove more effective at preventing error.
  “New technology [such as barcode systems] can accurately alert staff to, and prevent, inappropriate attempts to administer drugs to residents. This tool can reliably be used by care staff as well as nurses to improve quality of care and patient safety,” Szczepura remarked.
  

• Minneapolis Hospital Director Gets Proactive on Medication Errors
  Jan 26, 2012

  A Minnesota hospital’s pharmacy services director has found a way to stop harmful medication errors before they happen, saving patients from potentially life-threatening prescription drug mistakes.
  Director Bruce Thompson, ordered spot-checks of 37 patients who were recently discharged from Hennepin County Medical Center after a string of patient “bounce backs” pointed to medication errors.  The staff found that the facility’s record left something to be desired: 92 percent of all medication orders had some kind of error.
  For example, a kidney transplant patient was discharged from HCMC with an incorrect dose of antibiotics. Another patient who recently suffered a pulmonary embolism was sent home without a crucial blood thinner prescription.  Both cases resulted in the patients returning to the hospital.
  Thompson reported that the most common errors involved physicians prescribing an incorrect dose, patients taking duplicate medications or a lack of drug interaction detection.  One-third of the potential mistakes were classified as “likely harmful."
  The hospital instituted a new program in response: assign a pharmacist to check all discharge orders before patients are released from the hospital. In a little less than one year, the medication error rate has dropped to a negligible level and cut patient readmission rates in half.
  Hennepin County Medical Center was celebrated for its results, garnering The Institute for Safe Medication Practices’ 13th annual "Cheers Award" for "excellence in the prevention" of medication errors.
  Thompson has responded to calls from hospitals nationwide, encouraging them to start a similar program in their own facility.  He also says that some doctors now start their prescriptions by calling the pharmacist to confirm and check the order.   
  

• Reading the Packaging Can Prevent a Medication Error
  Jan 18, 2012

  Many people drive their cars everyday without ever reading the manual or plug in new appliances and throw the instructions out with the box.  So, it is any wonder that people often take medications for years without ever reading the instructions in the package?
  Doctors and pharmacists have often recommended that patients read the medication inserts that come with their prescriptions.  In addition to keeping patients informed about their care, these instructions can help patients detect an error before it happens.
  Another advantage to the written drug information is that it can be used for reference if the original instructions from a doctor or pharmacist are forgotten.  They are also included in over-the-counter medications, which is useful for those who did not seek a pharmacist’s advice before purchase.
  To make sure all patients can understand the information, all package inserts are required to follow a standard format and include the same groups of information.  Manufacturers may vary the format somewhat, but most leaflets look much like the standardized nutritional facts labels on food items.  Many have even gone one step further for comprehension, renaming sections such as “contraindications” to “who should not take this medication?” to draw a patient’s eye to important information.
  In a recent case, a Nigerian doctor received a phone call from one of his regular patients.  The woman was receiving treatment in the US.., and a physician prescribed a drug that was not supposed to be taken by a woman who was breastfeeding.  It was only by reading the leaflet that came with the medication that she was able to avoid a potentially-harmful prescription drug mistake.
  

• Arizona Teenager Receives Cancer Medication Instead of Painkillers
  Dec 29, 2011

  A 16-year-old in Mesa, Arizona narrowly avoided serious side effects after a pharmacy gave out the wrong medication. 

  Sean O’Connor was supposed to receive pain medication for his recent wisdom tooth extraction.  Sean had taken 17 of the pills the pharmacy gave him before the pharmacy called four days later to tell him they had made a mistake. 

  Instead of painkillers, Sean had been taking chemotherapy drugs. 

  “There was another guy at the pharmacy with my name … another Sean O’Connor, who apparently had cancer,” Sean remarked to the media. 

  Sean had a medical examination following the error which found his blood pressure was slightly elevated, but he was otherwise unharmed.  If he had taken the drug longer, however, he could have suffered sterility.  

  “I think it would be hard to get older and never have kids,” Sean said.

• Nurse Who Gave Patient Wrong Medication Faces Lawsuit for Fatal Drug Error
  Dec 25, 2011

  A Miami hospital is facing a serious drug error lawsuit after a staff nurse gave an elderly man the wrong medication.

  79-year-old Richard Smith was being treated for kidney disease at North Shore Medical Center in Miami. After he reported shortness of breath during a dialysis treatment, he was admitted to the ICU.

  On July 30, 2010, Smith was prescribed a course of antacids to combat an upset stomach. When Smith’s son Marc arrived later that morning and found find him unconscious and hooked to a respirator, the nurse explained that Richard Smith had experienced a cardiac arrest.

  The doctor explained to Marc Smith that Richard’s heart stopped after the nurse administered the wrong medication. Instead of an antacid, the nurse gave him pancuronium—a drug used during intubations to relax muscles.  A powerful paralytic, pancuronium is also used in high doses to administer lethal injections.

  Thirty minutes after the error, Richard Smith was found unconscious with no pulse. The doctors were able to restart his heart, but the loss of oxygen left him brain dead, and he remained in a coma until his death a month later.

  According to the Florida Agency for Health Care Administration, there are a number of safeguards in place to prevent these errors—and Smith’s nurse would have had to ignore them in order to make a fatal mistake.

  The nurse had said that the mistake occurred because the antacid and the paralytic had similar packaging, and he grabbed the wrong one. Per regulations, nurses are required to read medication labels, scan the package for dosage instructions, and match the patient ID to the medication.  The nurse did not take any of these steps.

  Although the hospital has removed pancuronium from nursing areas except the operating rooms, the nurse under investigation has not been suspended and is still working in the same unit where the error occurred.

  Our condolences are extended to the Smith Family as they cope with the loss of their husband and father.

• Woman Visiting from Egypt Falls Victim to Texas Walgreens Prescription Error
  Dec 01, 2011

  Nahla Said Naiel came to Texas for medical treatment for a heart condition.  Naiel, a resident of Egypt, was staying with family in Houston this month while she saw her doctor about her high cholesterol. 

  The doctor decided to change her course of medications.  He gave her a prescription for Crestor, which she filled at a Walgreens in Katy, TX.  She had been taking the medication for four days when she began to feel sick.

  "I feel my heart boom, boom, boom, boom, all the night. I can't sleep," she said. 

  She was visiting relatives in San Antonio when a cousin noticed that the name on the prescription label was someone else's.  The family went on to discover that the drug in the bottle was not Crestor, but Bumetanide—a diuretic. However, the Walgreens receipt Naiel received was printed with her correct information.

  "I know it's an unintentional mistake, but we need to be very careful. It's medicine," said Nabil El-Sharkawi, the cousin who noticed the error.

  Naiel asked her family members to help her get in contact with the man whose medicine she mistakenly received.  As it turns out, the man had also been given a wrong medication from the Walgreens in Katy a few weeks earlier.

  The man explained that when he notified Walgreens, the pharmacist corrected the mistake and apologized. Naiel also got an apology and correct prescription, plus a full refund—but she remains concerned that this type of mistake will happen to someone else.
  
  The Texas Pharmacy Board reported that it received 193 complaints in all of last year. This medication error epidemic is underreported across the country, so the statistics do not reflect all instances of prescription error. You can help prevent prescription mistakes from happening to other people by hitting the pharmacy companies where it hurts – in the pocketbook. Order our free pharmacy error book today, or call 888-526-7616 to have our prescription error attorneys review your case with no obligation and no charge. 

• IV Mistake Leads to Fatal Overdose in California
  Nov 30, 2011

  Drug errors in Texas can be frightening—but are unfortunately common.  It is estimated that 100,000 people will die every year as a result of a medication mistake, making medical mistakes more deadly than car accidents or breast cancer.

  And hometown pharmacies aren’t the only risk—many people are injured or even killed while receiving hospital care.

  For a patient in California, this was exactly what happened.  The woman, a mother and grandmother, was undergoing a routine procedure when a hospital pharmacist mislabeled her IV injection.

  The syringe, filled with saline and sterile talcum powder, killed the patient within seconds.

  Her daughter, Ruzanna Poghosyn, witnessed the overdose along with her husband, Robert.

  "She screamed out, 'Oh my God... Robert!' and that was it,” Poghosyn said. “those were the last words she ever spoke.”

  The family’s attorney discovered the pharmacist’s mistake: According to FDA regulations, all talcum powder solutions of this type must be labeled 'Not for IV administration.'  Instead, the pharmacist had typed the opposite: "For IV administration."

  Poghosyn believes that her mother died as a result of gross negligence, stating that "the pharmacist should have known that talc solution cannot be administered in an IV.”

• Automated Pharmacies Make Fewer Medication Mistakes than Staff
  Nov 29, 2011

  A new automated system could cut down the number of injuries caused by Texas pharmacy errors.

  Since most medication errors are a result of human misinterpretation of an order, it’s no surprise that using automated storage and retrieval systems cuts down on the number of pharmacy mistakes.  These machines both store the medications in rotating carousels and use software programs to manage drug inventory.

  The software, such as in machines from Talyst and AutoPharm3, verify the prescription and dosage using barcodes, resulting in a much more accurate system than relying on pharmacy technicians alone.

  These pharmacy automation systems are programmed to:

  • Stock, track, and receive all supplies
  • Document all transactions and supply orders
  • Perform accurate medication dispensing
  • Keep automatic track of expiry dates
  • Perform regular wholesale ordering
  • Prioritize orders and recognize emergencies

  Not only do these systems make fewer errors, they also use less space.  The machines take up less room than conventional shelving and drawer systems found in most pharmacies.  They have been shown to improve workflow by cutting down on walking and search time while filling patient orders, and could potentially take the place of extra staff members, resulting in smaller pharmacy workforces.

• After Prescription Mix-Up, Walgreens Promises to Pay Medical Bills
  Oct 30, 2011

  A patient is suing a Walgreens pharmacy for millions of dollars after the wrong medicine they prescribed "nearly killed" him.

  Ron Apenbrinck, of St. Louis, was supposed to receive Hydrocodone to treat his hernia. Instead, he mistakenly received medication for another patient: a heart-related prescription. The error occurred because Apenbrinck's name was on the pharmacy bag-but the other patient's name was on the prescription label.

  Apenbrinck, not noticing the name on the bottle, took the medication as he had been instructed for several days. Apenbrinck recalls that the pill made him dizzy, ultimately resulting in a fall from a ledge.

  "I was in a lot of pain, my wife was crying screaming for help," he said.

  After the accident, he spent nearly a week in the hospital suffering from a self-described mini-stroke. Medical documents attest that Apenbrinck has developed a variety of conditions since the drug mistake, including an irregular heartbeat and permanent injuries to his head, neck, back, and nervous system.

  As a result of his injuries, he is now taking 11 medications every day.

  Walgreens acknowledged the error in a statement, remarking that they have "a multi-step prescription filling process with numerous safety checks in each step to reduce the chance of human error." The company also assured the media that they "investigate what happens in each case and work to prevent it from happening again."
  
  As to compensation for this case, Apenbrinck's lawyer has said that a Walgreens employee at the South Kingshighway Boulevard location has apologized for the error, and the company has agreed to take care of medical bills.
  
  If you or someone you know have been affected due to presciption errors, contact an experienced pharmacy error attorney today.