I have blogged on this tragic story earlier. In 2006, Emily Jerry was receiving treatment for cancer at a Cleveland Hospital. She was due to leave the hospital after her treatment, and was getting a last round of chemo. However, a pharmacy technician at the hospital mixed the chemo drug with a saline solution that was more than 26 times the prescribed amount. Emily fell seriously ill as a result of the error, and died three days later. 

It’s hard to imagine that anything good could come out of this tragic death, but Emily’s parents have found a way to do just that. They have managed to use their tragedy for the greater good. They spearheaded efforts to pass Emily’s Law which was signed in 2009.  The law requires that prescription errors be reported to the Ohio pharmacy board, and that there be a limit on the number of technicians under a pharmacist’s supervision.

Scott Grossman is a pharmacy error lawyer representing injured victims of pharmacy errors in New Jersey and nationwide.

Last week, I blogged about a new national pharmacy error alert system that gives me some hope that preventable tragedies like these do not occur again. The American Society of Health System Pharmacists has collaborated with the Institute for Safe Medication Practices to launch a national alert system to prevent medication errors. The system will monitor serious medication errors that take place around the country, and will inform the ISMP network of approximately 35,000 pharmacists, as well as other health care professionals of the error, via email. The alert will come with a complete description of the error that has occurred, as well as guidelines to prevent these from occurring at the hospital.

It’s too early to say how successful this national alert system will be, but as a pharmacy error lawyer, I fervently hope that the system will prevent the kind of errors that have contributed to the death of this Minnesota victim.

If you have had any experience with pharmacy errors in New Jersey, l want to speak with you in connection with a special TV report on pharmacy errors. Please contact me at my office.

The victim John Sheridan, an attorney, developed melanoma on his back in 2007. The cancer quickly spread to his brain.  In September that year, Rite Aid issued a dose of a chemotherapy drug Temodar, which was much higher than his recommended dosage. According to the prescription, Sheridan was to take 14 capsules daily of Temodar.  That was roughly 10 times the normal dosage and almost double a fatal dosage. Rite Aid failed to spot the error, and filled out the prescription. Sheridan unwittingly took the high dose, which contributed to his cancer developing rapidly. Within the next month , Sheridan was dead.

When you undergo treatment for an illness, you expect that doctors, nurses and pharmacists in charge of your health are completely accurate in their diagnosis and treatment.  You depend on their sense of responsibility because as an ill person, or the loved one of a patient, you really don’t have a choice but to place your trust and faith in the hands of the doctor or pharmacists. The Rite Aid pharmacy here had a golden opportunity to correct a serious medication error

If you have had any experience with pharmacy errors in New Jersey, l want to speak with you in connection with a special TV report on pharmacy errors. Please contact a pharmacy error lawyer at my office.

Now, there is reason for pharmacy error lawyers to be encouraged. The American Society of Health System Pharmacies (ASHP) in partnership with the Institute for Safe Medication Practices (ISMP) is developing a national alert system that will alert doctors, nurses and pharmacists, when serious medication errors have occurred anywhere in the country.  

The alert system has been launched by actor Dennis Quaid who had a frightening experience with medication error-related injuries in 2007. His twin boys were administered an excessive dosage of the drug heparin, by a nurse. The twins were given a staggering 1,000 times the prescribed dose of the drug, and faced several days fighting for their lives. Fortunately, the Quaid twins made it through the nightmare. The error, a lawsuit claims, occurred because two bottles with different amounts of the drug shared similar packaging, with blue labels and a similar shape.

Errors like these are entirely preventable, and this new alert system should help address this issue.

If you have had any experience with pharmacy errors in New Jersey, l want to speak with you in connection with a special  TV report on pharmacy errors. Please contact me at my office.

The concept of having pharmacy chain employees on state pharmacy boards supposedly ensures that these boards have the expertise of seasoned professionals to draw from. While that may be true, it also ensures that the boards are staffed with a number of members who act to protect the interests of the pharmacies they work for. It reduces the concept of an "independent" state board regulating and overseeing the functioning of thousands of pharmacies in a state, to a farce.

Nobody should be too surprised when these board members who have vested interests proceed to veto decisions that are detrimental to the interests of the chain they work for. A perfect example to illustrate the conflict of interest here is the case of Tonya Pearson, a pharmacist at a Jacksonville Walgreen outlet, whose failure to catch a prescription error led to the death of Terry Paul Smith, a construction worker. When the employee came up for disciplinary hearings, a board member who was also a pharmacist at Walgreen, vetoed a fine of $10,000 on the erring Pearson. She got away with a $1,000 fine, and an "education program" to help catch errors – something Walgreen should have put her through before it allowed her to fill prescriptions at their outlet.

Such conflict of interest has riled advocates of better separation between the regulator and the regulated. But, the status quo continues merrily, and the only sufferers are victims of prescription errors like Terry Paul Smith. It's injustices like these that inspire pharmacy misfill lawyers who often turn out to be the only line of defense against well connected, big name chain pharmacies and their widespread sphere of influence. 

Physicians in some counties already have the e-prescription system installed, and have been using it with success. There has been a lot of positive feedback about the system that allow doctors to maintain records of patients, and then send their prescriptions to the pharmacy to be filled and ready by the time the patient gets there. The program is part of a nationwide promotion of the system by the federal government including a Medicare bonus incentive for doctors who prescribe through the system, that's expected to kick off in 2009.

But the biggest advantage could be in the doing away with handwritten prescriptions, often in a physician's illegible handwriting, and the move to an electronic system which is uniformly legible and understandable. This takes away at least one factor that results in pharmacy errors, out of the equation - doctor's often hurried and unintelligible handwriting. But the system does not factor in the other aspects that often play a greater part in pharmacy errors, like the speed with which prescriptions are filled. Pharmacists at chain pharmacies are often under pressure to fill as many prescriptions as humanly possible, or have incentives to do so which only increases the risk for potentially dangerous medication mistakes. The system also won't take into account factors like fatigue, overwork, stress and others that can contribute to an error while filling a prescription. It also won't deal with similar sounding drug names.   Already, pharmacists complain that the system comes with some software issues that could compound the error potential. For instance, the system dispenses directions for liquid medications along with tablet or capsule prescriptions. Plus, it takes time to set up, although it's easy to use once it's actually installed.

There are an approximate 85,000 doctors around the country who have electronic prescription systems installed, and more than 70 percent of pharmacies in the country accept these. How well the system will work over the long run, especially after the bonus system adds incentive to prescribe electronically, will have to be seen.

As this report reveals, because of this protective system, citizens have no way of telling how many errors a particular pharmacy or pharmacist has scored on their tally. The State Board of Pharmacy only releases records to the public in case there is any disciplinary action taken against the pharmacist in question, for his error. The Board admits it takes this step to protect the pharmacies and pharmacists. The pharmacies may be safe and protected. But who, we wonder, is responsible for protecting citizens? When records are available for public review only in the event of a disciplinary action, then it becomes hard for people to know exactly how many pharmacies have been diligent in following regulations and maintaining safe dispensing practices, and how many have been casually sweeping pharmacy errors under the Board's carpet. 

The extent of protection and privacy that's being afforded to New Hampshire pharmacies and their pharmacists is of concern to citizens' groups who worry about the lack of transparency in the oversight system. If all you can expect in case of an error is that the Board will decide whether to merely let off the pharmacist with an unrecorded warning, or take it to the next level, then it becomes hard to make any assumptions about the safety of your regular pharmacy. As Board members themselves point out, very few of the violations cases actually come up before the Board for action. Last year, inspectors brought exactly five pharmacy error complaints to the Board's notice. The year before that, the number was one.

To have pharmacists receive this level of protection from oversight and corrective measures is shocking to pharmacy error lawyers like me, who have been pushing for greater transparency and accountability in the country's' pharmacy chains. Citizens have the right to know how many pharmacists at exactly which pharmacy have been cited for errors. Ultimately, it's public health and safety we're talking about here, and there needs to be accountability.   

Emily had been diagnosed with an abdominal tumor, and had had been undergoing chemotherapy at the Rainbow Babies and Children's Hospital in Cleveland. The cancer was almost gone, and her parents were looking forward to taking her home. A trip to Disneyland to celebrate the disappearance of the tumor had been planned, and all that was needed to say goodbye to the hospital was one last round of chemotherapy. Instead, Emily woke up after the treatment in severe pain and vomiting violently. She died three days later. It was later that the pharmacy technician's horrible pharmacy error came to light.  

Now, a bill that was inspired by Emily's tragic and utterly preventable death has been approved by the Ohio state legislature. Emily's Act will seek to establish stricter regulations for pharmacy technicians, who will now be required to have at least a high school diploma, pass a state pharmacy proficiency exam and undergo criminal testing before they can show up for work.

There are two tragedies here – Emily's death, and the fact that it took the loss of a 2-year-old's life to wake up to the fact that too many patients were being subjected to the dangers posed by untrained and uninformed pharmacy technicians.    For hospitals looking to cut their overheads, it makes cold financial sense to have a number of technicians who are responsible for checking dosages, and placing the medications into containers, because they can get by with paying them a lower wage. Senator Timothy Grendell, the bill's sponsor admitted that he had faced "resistance" from pharmacies over the proposed measure that would mean higher salaries for trained technicians who met the new standards. 

In New Jersey, we're currently facing the prospect of a law that would limit a pharmacist's liability in the event of a mistake, so it's great news to have much needed legislation pushing for better standards elsewhere in the country.   

This bill titled "The Pharmacy Quality Improvement and Error Prevention Act S-409" has been introduced by Senator Jeff Van Drew, and claims to seek to establish strong measures to prevent pharmacy errors across New Jersey. These measures include the creation of a Medication Error Prevention Task Force consisting of 24 members, that would be responsible for providing guidelines for the improvement of pharmacy quality control standards, and to reduce the number of errors that occur at New Jersey pharmacies.   The bill also require pharmacies in the state to monitor and review any pharmacy errors that may occur, and also mandates the State Board of Pharmacy to release regular alerts about prescriptions drugs that have similar sounding names, so that the frequency of errors is reduced. Pharmacists are required to report any medication errors occurring on their watch to the Board of Pharmacy.

So far, so good. 

The wheels seem to be spinning fast as this legislation moves ahead on its way to becoming a full fledged law. It will now proceed to the full Senate for consideration. Unfortunately, New Jerseyans seem to be unaware of the potential implications that this legislation has for their right to protect themselves, and claim compensation in the event of a pharmacy error-related injury. It removes any compulsion that big name pharmacy chains have to maintain quality standards in the dispensation of medicines to patients. Just a few weeks ago, I mentioned how CVS in North Carolina had an incentive scheme in place that rewarded employees for filling the maximum number of prescriptions in a single day. Lured by the incentives, pharmacists were topping 500 prescriptions a day, when the acceptable limit in that state is 150. A mad rush to fill prescriptions inevitably lead to mistakes, even fatal ones. If the bill is passed, customers who suffer from the consequences of these practices, will lose any rights they have to be compensated for their injuries.

It's become imperative that we draw attention to this issue that threatens to impact all New Jerseyans. To learn more about how this bill is bound to affect your lives, please contact me at my pharmacy error lawyers office.

Now, an identical bill “The Pharmacy Quality Improvement and Error Prevention Act A-1803" has been introduced in the Assembly by Assemblywoman Valerie Huttle. She has been busy promoting her legislation, hailing it as an effective measure to prevent the number of injuries that occur because of prescription mistakes in New Jersey.  

A registered pharmacist, who reports information to the board relating to a medication-related error, as required pursuant to subsection a. of this section, shall be immune from liability in a civil action for any injury or damages in connection with that medication-related error.

If the bill becomes law, what it will mean for New Jerseyans, is that in the event that they are injured because of a prescription error, the pharmacist who was responsible for filling the prescription will not be held liable for any injuries that were caused by his mistake. All that's required for the pharmacist is essentially to report his error to the New Jersey State Board of Pharmacy, to get away with a slap on the wrist, and not much more.

As a pharmacy error lawyer, I am all for legislation to prevent errors, and the establishment of an oversight committee that will act as a watchdog to prevent innocent consumers from having to suffer the often dangerous effects of prescription mistakes. What I cannot understand however, is the establishment of a Task Force that has just two members out of its 17 public members, representing the needs of health care consumers. The remainder of the members is made up heavily of chain pharmacies, pharmaceutical companies, and other allied interests.

Throughout the country, we're seeing big name pharmaceutical interests taking increasing precedence over the protection of the consumer. Whether it’s the eagerly awaited outcome of the currently ongoing Wyeth-Levine lawsuit that threatens to take away an individual's right to sue a company for injuries sustained by an FDA-approved drug, or this bill that jeopardizes the rights of New Jersey residents to claim liability when they have been injured because of pharmacy error, increasing legislative interference with the rights of citizens is a dangerous and continuing trend that must be curbed.  

The company in question is CVS, which has the highest number of stores – 285 of them - in the state out of all the nationwide chains. According to the report, the distinction with other chains doesn't quite end there. CVS also has the highest number of citations from  the North Carolina Pharmacy Board for prescription errors. In fact, the Board has repeatedly cited the chain for creating a work environment in which employees are likely to make mistakes.

Regular customers who get their prescriptions filled at CVS are noticing the difference in service, the report says. Staff members often seem to be in a hurry to rush through prescriptions. It's not simply a desire to squeeze more out of their workday that's behind this high speed work environment. As the report points out, the company has incentive systems in place that reward employees based on the volume of prescriptions they fill. In fact, CVS pharmacists routinely receive updates on the amount of extra cash they stand to make depending on how quickly they can fill bottles with pills.

The extent to which CVS has been able to continue this practice unchecked, is shocking. Consider these statistics – the Board of Pharmacy stipulates 150 as the number of prescriptions that can safely be filled by a pharmacist in a single day. At CVS, some former employees have gone on record to claim that on a busy day, it's not unusual for pharmacists to fill as many as 500 prescriptions.  

In one complaint of pharmacy error against CVS that was filed with the Board, a pregnant woman took home what she thought was anti-morning sickness medication from her local Salisbury CVS store.   Only, it turned out to be a drug that's prescribed for patients with spinal injuries. When the Board investigated the number of prescriptions that were filled on the day of the potentially tragic mistake – a common practice when pharmacy errors are reported – it was found that the pharmacist responsible had filled 513 prescriptions on that particular day.

CVS itself sees nothing wrong with the speed at which prescriptions are filled at its stores. According to a spokesperson, certain speed is necessary in "specific defined circumstances."   The blasé attitude at CVS towards the concerns of the Board and the public, as well as the company's focus on volume and profits at the cost of patient safety, is appalling. But it's far from an isolated case. The push for profits over safety is common to most of the major nationwide pharmacies. The kind of prescription errors that result when pharmacists are counting the dollars that will be chalked up on their incentive sheets, instead of focusing on the name of the medication they are filling out, should be a cause for worry, not only for pharmacy error lawyers, but also consumers.

Our thoughts and prayers are with Jessie Scott and his family.

Kiii.com, a television station in Texas, further reported that the premature twins, a boy and a girl born to Eric and Erica Garcia, were transferred to Christus Spohn after birth  and allegedly died from the Heparin overdose. While the hospital is not admitting responsibility for the twins’ death since they were born four weeks early, they are investigating the matter. It is of note that two of the staff pharmacy employees have taken temporary leave.

Our hearts go out to the Garcia family during this difficult time.

 Once again, I implore the public to be extra vigilant when shopping at these pharmacies. It is bad enough that we are forced to defend ourselves against prescription errors at the hands of pharmacists and their technicians; now simply going to the shelves for Tylenol or a can of Similac has become a potential health threat to us as well.

According to an article from the American Medical News, a shocking 11% of child patients have adverse drug events during hospital stays. Most of the results came from children staying in adult hospitals and given adult sized doses instead of the pediatric size. Dr. Sharek, chief clinical patient safety officer at Lucile Packard Children's Hospital in Palo Alto, Calif. said “We are so used to writing pediatric, weight-based doses and when children are being cared for at adult hospitals staffed by adult-based nurses and adult-based pharmacists, that's a type of error that could theoretically occur a lot more frequently." The American Medical News goes on to say “The Joint Commission, which accredits and certifies more than 15,000 U.S. health care organizations and programs, said in its sentinel event alert that children are at greater risk for adverse drug events. That's because most medications are formulated and packaged for adults, and most hospitals and emergency departments are geared toward caring for adults.” The Joint Commission is further investigating these problems and suggests that hospitals identify and administer pediatric medications. Frank Federico, RPh, said "Medication should be delivered to the nursing unit or available in ready-to-administer fashion. That way, there is less that nurses have to do and less chance for error.”

This time, in a  recent article on FoxNews.com, the victim was a baby with a sinus infection. The parents filled a doctor's prescription for Histacol DM syrup at a Palm Coast, Florida Walgreen's store. The dosage of the medication was to be a quarter of a milliliter. The prescription was erroneously filled by a Walgreen's pharmacy, who wrote the  dosage at a quarter teaspoon, six times the prescribed amount of medication.  Upon taking the first dosage, the baby became unresponsive and was rushed to the hospital, where doctors were able to stabilize the child. In a typical move,  Walgreen's offered $2,000 to make this bad story disappear, which the family refused.

-Zestril (high blood pressure) and  Zetia (cholesterol)

-Lamactil (epilepsy) and Lamisil (fungal infections)

-Celebrex (arthritis) and Celexa (antidepressant)

-Zantac (reflux) and Xanax (anxiety)

Scary, right? The article offers some helpful tips to protect yourself from a mix-up with potentially deadly consequences:

-Don't have your prescription telephoned in

-Make sure the script is printed in English (as opposed to Latin code or illegible scribble)

-Keep a copy of your prescription

-Double check the pills and the label BEFORE you leave the pharmacy