Recent Blog Posts

Unchanging High Rate of Medication Errors Demands New Solutions

Scott Distasio — Tue, 15 May 2012 20:19:00 GMT

In 2007, the Institute of Medicine (IOM) released a report indicating at least 1.5 million people each year are the victims of some kind of medication error. According to CNN, a separate study from 2006 showed at least one hospital medicine error per patient, per day. These troubling statistics prompted many patient care advocates to publish suggestions for people who wanted to avoid becoming victims of drug mistakes.

Dr. Albert Wu, who assisted with the IOM report, offered the following tips:

1. Get in your doctor's face. Make sure you know what the doctor has prescribed, how much you should be taking and how often you should be taking it. Ask questions if you are confused.

2. Get in your pharmacist's face. Double check the information on your prescription bottle and again, ask questions. Do not assume you were not given the wrong medicine, make sure it is correct.

3. When in the hospital, get your medication list in writing. Make sure you know what you are taking and how often you are taking it. You should also find out if you are being given pills or if it is an IV.

4. Make sure you are getting YOUR medicine. Have the nurse verify the information on both the medicine and on your hospital ID bracelet before you take it.

5. Get dramatic if you have to. If hospital employees do not listen to your concerns, make them listen. A seriously phrased verbal request should work.

These suggestions are good advice, but as a medicine error lawyerI know they cannot be the only solution to the high rate of drug errors made every day. Doctors, nurses, and pharmacists have more training and more knowledge about medications than patients typically do. It can also be very difficult for a hospital patient to keep track of all of his or her medications, particularly when they can change frequently.

Despite the fact many doctors have begun to use electronic prescription systems and many hospitals have turned to automated medication dispensers, the rate of drug errors has not significantly decreased. Health care providers cannot rely solely on technological advances and their patients to reduce the rate of medicine mistakes.

Pharmacies, hospitals, and doctors are not required to report their medication errors and often do not report them in order to avoid penalties. This needs to change and a system for tracking mistake commonalities needs to be implemented to truly address the problem of prescription mistakes.

Pharmacy Errors More Common Than People Believe

Scott Distasio — Thu, 10 May 2012 19:41:00 GMT

Every day, patients around the developed world put their trust in pharmacists. These men and women have gone through years of schooling and training and know more about medications we take than we do. There are set procedures they follow when preparing prescription medications and safeguards to protect against mistakes. Pharmacists also use powerful computer programs to ensure patients are not given the wrong medicines. For all of these reasons, most people feel little concern when they drop off a prescription to be filled and they feel confident when taking their drugs that there have been no pharmacy errors.

An investigation by News Channel 5 indicates that pharmacy medicine mistakes are far more common than people are lead to believe. Florida state data shows that in the last five years only 130 of the 40,000 licensed pharmacists have been disciplined for a medication error. However, the state of Florida does not require a pharmacy to report an error. Dr. Carsten Evans is a professor at Nova Southeastern University and head of one of the nation's two remediation programs designed to help pharmacists understand their errors. She explains, “Unless there's a death, [the error] stops there.” Fearing consequences, most pharmacists do not report their mistakes, making pharmacy medication errors a severely under-reported problem. Since it is under-reported, most people do not know about it and it is not being addressed properly.

There is only one federally recognized program in the United States dedicated solely to preventing drug errors, the Institute for Safe Medication Practices. Executive Director Michael Cohen cites company quotas as one of the main sources of pharmacy mistakes. Quotas require pharmacists to fill a certain number of prescriptions per hour. This can cause them to rush and lead to mistakes. Ultimately, Cohen argues that is is important to “look more at reporting these nationally and fixing the problem. There needs to be that safety oversight to make sure people are doing what they’re supposed to do and to make sure procedures are in place.”

Eye Infections Linked to Pharmacy with History of Errors

Scott Distasio — Sat, 05 May 2012 15:40:00 GMT

Compounding is a process in which a pharmacy mixes medications using bulk ingredients. They are often used when a patient is allergic to inactive ingredients in commercially available and FDA-approved medications. Doctors may also use compounds when patients need alternative doses or forms of delivery than are commercially available.

Franck's Compounding Lab has previously been investigated for pharmacy negligencewhen 21 polo horses died after being given a compound from the lab. The lab later admitted to using too much of a mineral in the mix, leading to the overdose. The FDA then accused the pharmacy of illegally creating copies of similar drugs. While the lab states they are compounding, the FDA argues the pharmacy is simply manufacturing commercially available medications. Furthermore, questions have been raised as to whether or not the lab is using drugs that have not been approved for use in the United States.

Now Federal health officials linked 33 cases of a rare fungal infection of the eye to products mixed in the Ocala pharmacy. According to CBS News, the victims of the eye infection had all recently had either eye surgery or eye injections. 23 of them suffered some vision loss and 24 had to have additional eye surgery as a result of the fungus. The CDC traced the cases to two products – a dye and an injection including triamcinolone. California health officials reported nine medication related infections to the CDC in March, the same month in which the lab recalled several lots of the defective dye and one of triamcinolone. The lab has not halted production of other sterile compounded products, which include chemotherapy drugs. The CDC has warned doctors against using Franck's products labeled sterile.

In response to this outbreak, the pharmacy claims to have made several changes including hiring a new pharmacist to oversee quality and prevent further pharmacy mistakes. State health officials can neither confirm nor deny whether or not the facility is under investigation.

Poor Math Skills Linked to Medication Dosage Errors

Scott Distasio — Mon, 30 Apr 2012 21:32:00 GMT

At the Pediatric Academic Society's annual meeting this past Saturday, the findings of a new study were presented. According to the study, children are much more likely to receive the wrong dose of a medication if their parents have poor math skills.

ABC 7 reports the study focused on 289 parents of children under 8. These children were prescribed liquid medication by doctors at a pediatric emergency department. The parents took tests which measured their math and reading skills. They were also observed readying doses of the medication for their children.

Of the parents who participated, approximately one third had poor reading skills and 83 percent struggled with math. 27 percent of the participants had math skills at or below a third grade level. During the study, 41 percent of parents made medication dosing mistakes. Researchers found the parents who had lower math skills were five times more likely to make a drug error.

The study's authors cited a difficulty in converting between units of measurement as one of the primary causes of the dosing errors. Dr. H. Shonna Yin, assistant professor of pediatrics at New york University School of Medicine and Bellevue Hospital Center, co-wrote the study. According to Yin the research results may help doctors improve their dosage instructions. Solutions like demonstrating how to measure a dose and providing photos of a properly measured dose were discussed.

Rite Aid's Wellness Ambassador Program Raises Concerns About Pharmacy Mistakes

Scott Distasio — Thu, 26 Apr 2012 21:18:00 GMT

If you are traveling and fall ill, you may find yourself at a Rite Aid pharmacy looking for relief. You may find a counter manned by an employee in a white coat, there to offer advice on medications and symptoms. And you might think you are speaking with the pharmacist on duty when in reality, you are talking to one of Rite Aid's Wellness Ambassadors.

Rite Aid began the Wellness Ambassador program in an effort to improve customer service. The Ambassadors are meant to serve as greeters, to act as customer liaisons to pharmacists, and to assist in locating products. But the white coat and potential proximity to the pharmacy counter have raised questions about the program and its potential for pharmacy mistakes.

According to the Daily Finance, Senator Dick Durbin (IL) and Senator Richard Blumenthal (CT) have drafted a letter to Rite Aid's CEO taking issue with the Wellness Ambassador program. They cite recommendations of non-FDA approved supplements and reports of harmful outcomes after patients take the Wellness Ambassador's advice as concerning. Some reports have come in that patients have been advised to consider a vitamin regimen to help in cancer prevention. In reality studies have shown there could be a link between these vitamins and cancer.

Ultimately, the concern is based on non-medical experts giving medical advice, the potential for drug interactions, and the potential for medicine mistakes. Patients who believe they are speaking with a pharmacist when talking to a Wellness Ambassador may not raise questions about their medications with the actual pharmacist. They may ask the Wellness Ambassador to interpret their dosing instructions or other information. The program itself is not flawed, so long as the Wellness Ambassadors do not offer advice on medications or supplements and do not wear the white coat of a pharmacist.

Concerns Raised Over Practice of Filling Prescriptions In-Office

Scott Distasio — Thu, 19 Apr 2012 18:45:00 GMT

Over the past few years, more and more doctors have stopped writing prescriptions for their patients. Instead, they dispense the necessary medicines in their offices. This process has raised some questions from patient advocates and health care officials alike.

Those who support the idea of doctors selling prescription medications in their offices argue that it is a huge benefit to patients. According to Philly.com, proponents claim it is more convenient for patients. Advocates also assert that if doctors are more familiar with the cost of medications they will be more likely to use generic forms or other substitutions to save patients money. Furthermore, when doctors are the ones dispensing medications, prescription orders cannot be misinterpreted, which may protect against patients receiving the wrong medicine.

Despite the apparent benefits, there are also those who have expressed numerous concerns. Doctors may not have the full, updated list of every medication a patient takes, which could result in bad drug interactions. They also are unlikely to have pharmacy software to track potential medicine mistakes. A pharmacist also serves as a second set of eyes to examine prescriptions and act as a safety net.

Additionally, doctors are not subject to the same regulations as pharmacists. They are not required to have standard labels on their medications and questions have been raised over whether the doctors are the ones filling the prescriptions or if other office staff members dispense the medication and consult with patients. Questions have also been raised on the possible conflict of interest and whether doctors might be tempted to prescribe more expensive medications in order to make more money.

FDA Proposes Changes to System For Monitoring Drug Safety Issues

Scott Distasio — Mon, 26 Mar 2012 18:37:00 GMT

Over the past year and a half the Food and Drug Administration (FDA) has come under fire from medical experts. In articles published in several medical journals, experts have questioned the agency's response to and reporting of medication errors, adverse drug events, and other medicine safety concerns.

The FDA maintains a database of medicine issues and drug mistakes known as the Document Archiving, Reporting and Regulatory Tracking System (DARRTS). This database is meant to archive “Tracked Safety Issues” (TSIs) which are problems related to various medicines. By tracking issues, officials can potentially uncover previously unknown information about drug dangers.

However, healthcare experts argue FDA officials use the database inefficiently. Researchers published a study in January's issue of Medical Care that indicated the FDA was inconsistent in reporting risks to the public and to healthcare professionals.PM Live.com reports similar conclusions were published in other health journals. As a result, information about medication safety issues are often not communicated in a timely and effective way, putting patients at risk of medicine mistakesand bad drug reactions.

In an effort to improve their procedures for handling medicine issues, the FDA has proposed new guidelines for how to handle reports of drug errors. It categorizes issues into three levels: priority, standard and emergency. Those deemed to be of priority or emergency level would be monitored and timelines for decision making and action would be followed to ensure information is made public in a timely manner. When categorizing these drug safety concerns, FDA officials will examine what kind of event was reported, how many people were exposed, and how likely it is that people will be harmed.

The FDA has published their proposed changes in a draft available to the public. Citizens are welcome to submit their comments on the draft to the FDA.

Patient-Controlled Analgesic Pumps May Cause Medication Errors in Hospital Patients

Scott Distasio — Tue, 20 Mar 2012 19:19:00 GMT

Any hospital patient who has counted the minutes until her next dose of pain medication can tell you how agonizing that wait can be. Hospital staff accept that medication is “on time” so long as it is administered 30 minutes before or after the scheduled time for the next dose. If a nurse is dealing with an emergency or another patient, the time between doses could potentially be extended. For these reasons, some hospitals employ the use of patient-controlled analgesic pumps (PCAs). These machines allow patients to self-administer pain medication as needed based on their prescriptions.

The Morning Call reports that after three patients at a Pennsylvania hospital were injured due to drug overdoses associated with patient controlled pumps, the Pennsylvania Patient Safety Authority investigated the use of PCAs. Investigators found that between 2004 and 2010, 4,230 problems were reported and 20 percent of those experiencing issues were injured or killed. These problems were typically medicine errors where the wrong amount was programmed into the PCA, allowing the patient to overdose.

In an effort to reduce the risk of overdose, some hospitals have begun using smart pumps. These models include an alarm that will sound if a programmed dose exceeds pre-set limits, reducing the risk of a pharmacist, doctor, or nurse making a miscalculation leading to a patient getting the wrong dose. Hospitals typically verify the medication dosage independently in addition to relying on the PCA in order to prevent hospital drug mistakes.

Manufacturers are working to improve patient-controlled pump technology to further reduce the risk of accidental overdose. But PCAs are subject to other problems as well. In some cases, patients using the pumps are poor candidate for the systems. Those who are underage, overweight, confused, or on other medications should not use the pumps. Doctors and nurses must also ensure patients are not given the wrong medicine. For example, in some PCA cases, morphine and hydromorphone are mixed up. Hospitals must continue to put policies and procedures in place to safeguard all medication errors.

Woman Nearly Dies Due to Hospital Medication Error

Scott Distasio — Thu, 15 Mar 2012 19:20:00 GMT

Anita Griffie sought emergency medical help at Gaston Memorial Hospital last November when she had trouble breathing. With congenital heart failure, she was frequently in and out of the hospital for treatment. On November 14 a nurse told Griffie she would be administering potassium when in reality Griffie was receiving IV insulin. When a non-diabetic like Griffie receives such a high dose of insulin, it can be deadly. As she began to lose consciousness, Griffie was able to bang on a wall to call for help.

The hospital was able to identify the drug mistake before Griffie was permanently injured. Griffie and her husband considered hiring a hospital drug error attorney, but North Carolina law makes it difficult for patients who were given the wrong drug to file a lawsuit unless they are maimed by or die due to the mistake. While they have not retained a medicine mistake lawyer, federal investigators are now looking into the hospital's records and practices.

The Griffies reported the hospital's error to state regulators. Because of the drug error, Gaston Memorial is on Medicare's immediate jeopardy list and may lose Medicare funding if policies and procedures are not amended to ensure patient safety. The Griffies believe the error occurred due to the hospital being understaffed. Three new registered nurses have since been hired in an attempt to keep Medicare funding.

Eye Drops and Wart Remover With Similar Sounding Names Results in Prescription Error

Scott Distasio — Tue, 13 Mar 2012 20:50:00 GMT

When a doctor prescribes you a medication and you take that order to a pharmacy, you do not expect to be given the wrong medicine. You expect to take the prescription and feel better, not that it could make you sicker. But sometimes staff members do make pharmacy mistakes that can have serious consequences.

In late 2011, doctors were warned about a potential medicine mix-up between two very different medications with similar names. Reuters reports a pharmacist confused the two drugs Durasal and Durezol in the most recent case of mistaken identity. Durasal is a wart remover that includes salicylic acid. It is very different from Durezol, which is a steroid eye drop used after eye surgery.

If patients are prescribed the eye drops but instead get the wrong drugand use the wart remover in their eyes, they can suffer a serious injury. Wart removers like Durasal are not meant to be used on the face due to the high concentration of salicylic acid. Safety warnings say that if the solution accidentally gets in the eye it should be flushed with water for fifteen minutes. But a patient who received the wrong drug would not know it and would not flush his eyes after putting in what he thinks to be eye drops.

Typically, the FDA screens medicine names to try to avoid such confusion. However, since the wart remover is not FDA approved, the similarities in the name were not caught. The distributor, Elorac, has not responded to requests to stop selling the wart remover.

Nursing Home Pharmacy Errors Linked to Illegal Kickbacks

Scott Distasio — Wed, 15 Feb 2012 19:50:00 GMT

An investigation by the California Department of Public Health uncovered numerous pharmacy errors made in nursing homes. During the course of the probe, officials found one woman with a history of seizures was being given two drugs that are known to increase the risk of epileptic events. She was also prescribed two different antipsychotic medications, which combined put her in danger of irregular heartbeats.

According to the New York Times, 18 of the 32 investigations conducted between May 2010 and June 2011 uncovered incidents where pharmacists failed to note when patients were prescribed the wrong drug. In other cases, pharmacists failed to note when patients were given the wrong dose. Furthermore, in 90 percent of cases, pharmacists failed to identify the nursing home abuse of antipsychotic drugs.

Investigators suggested that the pharmacy mistakes could be linked to the fact that nursing homes involved are paying the pharmacy companies less than the cost of providing the services. On average, a California pharmacist makes $56 an hour. Nursing home records indicate some of the pharmacists making the “mistakes” were making as little as $11 an hour.

It appears the pharmacy companies are willing to provide the pharmacy review service below cost to get their foot in the door at the nursing home. Once the company is providing the review services at the nursing home, its pharmacists can provide residents with profitable drug products supplied by the company and bill Medicare, Medicaid, and other payers a profitable rate for these other services. In fact, in November of 2009 Omnicare, the nation’s largest long term care pharmacy provider agreed to pay $98 million to the federal government to settle allegations of overcharging for these other services after providing the review services at below cost.

Medication Recalled Due to Concerns of Prescription Painkillers Being Mixed with Over the Counter Drugs

Scott Distasio — Mon, 13 Feb 2012 22:09:00 GMT

A Novartis medication plant in Lincoln, Nebraska manufactures both over the counter medications like Excedrin and powerful prescription painkillers like Percocet. Due to a potential medicine mix-up, Novartis has recalled some packages of Excedrin, NoDoz, Bufferin, and Gas-X.

The Chicago Tribune reports there have been no confirmed incidents of the prescription drugs being found in over-the-counter bottles. The recall was enacted due to complaints about broken pills and inconsistent packaging. Novartis voluntarily shut down production while it enacts safeguards to prevent drug confusion in the future.

The prescription drugs Percocet, Endocet, Opana, and Zydone have not been recalled due to concerns about a potential shortage as the facility in Nebraska has been shut down. FDA experts say “the likelihood of finding a wrong tablet in an opiate pain medication dispensed to patients is low and patients should not be unduly alarmed.” However, if patients find pills in their medication that look different from the others, they are encouraged to return the medication to their pharmacy.

For more information about the recall, customers can contact Novartis at 1-888-477-2403 Monday to Friday, 9 a.m. to 8 p.m. EST.

Does Partier Deserve Compensation for Overdosing On Someone Else's Stolen Drugs?

Scott Distasio — Sat, 28 Jan 2012 18:08:00 GMT

In 2007, New Jersey teen Scott Simon attended a party and took the Xanax another party-goer was passing out. Then 17, Simon fell into a coma after taking the drugs. Instead of calling for help, the other guests continued the party before eventually taking Simon to the hospital. Today Simon cannot walk without help and also has difficulty talking. Simon hired a medication error lawyer to bring a personal injury lawsuit.

According to NJ.com, the Xanax was stolen by a former employee of a local pharmacy. Simon's bad drug lawyer has filed suit against the pharmacy, the parties host, the host’s parents, and various other party guests. The pharmacy error attorney’s theory against the pharmacy was that it did not take the proper precautions against theft. The theory against the host’s parents was that they left town during the event. The theory against the host and other party guests was that Simon should not have been given the drug and that he would not have suffered permanent nerve damage if he was treated immediately.

Simon's medicine mistake attorney admits Simon does share in the responsibility for his injuries since he took the drugs. But the pharmacy, party goers, and homeowners should still be held accountable for their part in the accident. A settlement was reached in the case and Simon will receive $4.1 million for his injuries.

Changes to Infant Medicines May Confuse Parents and Increase Risk of Overdose

Scott Distasio — Mon, 23 Jan 2012 16:56:00 GMT

I recently discussed the dual problems of accidental overdose in children and accidental overdose of acetaminophen. The Food and Drug Administration's attempts at reducing the risk of both may have backfired, making it more difficult to make sure children do not get the wrong dose.

According to USA Today, different versions of acetaminophen medicines, which include brands like Tylenol, Triaminic, and Pedia Care, may have different concentrations. Concerned with the high risk of accidental overdose, the FDA has requested manufacturers change to less concentrated formulas. But this change is voluntary, so not all products have the same amount of medicine in them. Experts are concerned this could lead to confusion and further issues with children getting the wrong amount of medicine.

In order to safely administer medications to children, the FDA suggests parents carefully read all packaging before giving any drugs. Assumptions about the medicine based on when or where it was purchased should not be made and any questions should go to a qualified health care professional.

Pharmacist Medication Review During Hospital Stay May Reduce Errors

Scott Distasio — Wed, 18 Jan 2012 08:00:00 GMT

The American Society of Health-System Pharmacists examined a program in which hospital pharmacists were involved in discharging patients. According to the study, the percentage of patients discharged with a hospital medication mistake was reduced from 76% to 47% when pharmacists were involved in the process. The study also indicates that such pharmacist involvement reduces the average number of errors per patient from 2.5 to 1.8.

According to Medpage Today, the study was based on a program of medication reconciliation in which a pharmacist reviewed all medications that a patient was to continue after discharge. Any drug mistakes that were identified were brought to the prescribing doctor's attention. Pharmacists also explained to patients how and when to take their medications and discussed the importance of following their drug treatments.

Errors in which patients were discharged with the wrong kind of medication like a nebulizer treatment instead of an inhaler, were reduced from 33 to 11. Patients were less likely to receive wrong medicine instructions. With pharmacist involvement, these errors dropped from 83 to 38. Duplication mistakes where patients were prescribed two forms of what is essentially the same medication were reduced from 18 to 1.

But other data showed no difference in the number of hospital drug errors before and after the pharmacist involvement program was implemented. Approximately the same number of patients were discharged either missing a medication they should still be taking or taking a medication that was no longer necessary. This shows that no program is perfect. Hospitals and providers must continue to work to reduce the risk of a medication error to protect their patients.