Pharmacy Misfills - New Jersey Accident and Injury Law Blog

3 Month Old Florida Baby Victim of Pharmacy Error

scott@grossmanjustice.com (Scott Grossman) — Mon, 12 May 2008 21:05:35 -0500

A large chain pharmacy commits another mistake by mislabeling a three month old's prescription with the wrong dosage. I used the word mistake here because it is a well known way to describe pharmacy errors but the truth is that the words "pharmacy mistake" sound way too innocuous for these situations.

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.

]]>My experience with clients who have fallen victim of "pharmacy error" or "pharmacy mistake" at the hands of the large drugstore chains has taught me that Walgreen's would have made any settlement conditional upon the family signing a strictly enforced confidentiality agreement. This is of course done to shield pharmacy's from bad publicity and to prevent the public from knowing the truth about the frequency at which these mistakes occur. Good for the Ruddell family who decided to go public with their story in order to inform others about what happened and to try to help save others from the same mistake.

A Pharmacist Believes that Pharmacists Cause Errors

scott@grossmanjustice.com (Scott Grossman) — Wed, 13 Feb 2008 11:01:16 -0500

There was an article on USAToday.com which excerpted an interview with a young pharmacist (who incidentally is now enrolled in law school), about pharmacy errors. It was a pretty interesting article, as it gave another view as to who is ultimately responsible for prescriptions that are filled and dispensed to the drug-consuming public. The pharmacist, Eli Phillips, Jr., a second generation pharmacist (his dad is a pharmacist too), was quoted as saying "Ultimately, the pharmacist is responsible for every prescription that leaves, whether it is correct or incorrect. It's all on the pharmacist. The technicians are there only as a means of support."

]]>His candor is refreshing and quite the contrary to the usual rhetoric the public is fed about why misfills occur. There is a lot of blame shifting, on to the public, to the doctor's messy handwriting, to the way the pharmacy itself is laid out, to the issue of whether there is a drive-thru at a given location, to corporate policies and overworked pharmacists. I agree with Mr. Philips' conclusion, that despite all of those other distractions, there is no one else to blame for a medication dispensing error of any magnitude than the pharmacist him or herself. There must be accountability, and if pharmacists believe that their working conditions are causally related to the incidence of prescription errors and misfills, then they need to rise up and do something to change the status quo. The American public can only do so much to protect itself here; there must be a way to restore our faith in the American pharmacist. A little honesty, a la Mr. Philips is a good start.

Report Reveals Similar Drug Names Often Lead to Serious Mix-Ups

scott@grossmanjustice.com (Scott Grossman) — Fri, 08 Feb 2008 10:32:50 -0500

I found this article on courant.com about a report recently released by standard-setting organization for the pharmaceutical and dietary supplement industry, U.S. Pharmacopeiahas, or USP, which found that there are at least 3000 pairs of drugs with similar names, which is contributing to the high incidence of pharmacy dispensing mistakes. Here are a few examples:

-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

Don't Use the Pharmacy Drive-Thru

scott@grossmanjustice.com (Scott Grossman) — Wed, 23 Jan 2008 10:20:57 -0500

A recent article on Science Daily.com reported on a study which revealed that pharmacists who work at pharmacies with drive-thru service windows feel that the drive-thru causes distractions that may lead to delays and dispensing errors.

]]>The pharmacists' beliefs about the impact drive-thrus have on the quality of delivery of service was studied by a professor or pharmacy practice and administration at Ohio State University. The pharmacists were asked to complete a detailed questionnaire which sought their opinions about how their work-flow was impacted by such things as the pharmacies' physcial layout, whether there was a drive-thru on site and whether there was an automated dispensing system. Overwhelmingly, the pharmacists responded that the presence of a drive-thru window was the most problematic aspect of their practices because it placed a lot of pressure on the pharmacy staff to multi-task leading to potential dispensing errors, delay and reduced efficiency. The pharmacists involved in the study made some suggestions on how to remedy the problem posed by the drive-thru– automated dispensing systems that count tablets or are linked to the pharmacy computer system enabling them to complete the entire dispensing process. Automated dispensing systems are typically used for medications that are in particularly high demand, such as antibiotics, blood pressure medications and painkillers.

The survey results cited by Science Daily.com were published in a recent issue of the International Journal for Quality in Health Care. Szeinbach co-authored the study with Enrique Seoane-Vazquez and graduate students Ashish Parekh and Michelle Herderick, all of Ohio State’s College of Pharmacy.

Yet Another Case of Pharmacy Error

scott@grossmanjustice.com (Scott Grossman) — Tue, 11 Dec 2007 20:46:59 -0500

A report out of Columbus, Georgia late last week revealed that a woman went to her local CVS Pharmacy to fill a Vicadin prescription for her son who sprained his ankle. The prescription was for twenty pills, but the pharmacist put 90 pills in the bottle. Horrified, and afraid of what could happen if someone got his hands on these excess pills, she called the pharmacy to report it. At that time she was told to either bring them back or throw them out, and when she told the pharmacist that she might not be able to get back to the store that night, she was told to, “Do what you want with them. Keep them. It doesn’t matter.” This did not sit well with the worried mother who then contacted the Georgia Narcotics Agency, who advised that she return the excess pills to the CVS, and when she went to do just that, the pharmacist refused to take them back. What an incredulous error in light of the fact pain killer prescriptions are to be checked by three different pharmacy staffers, including the pharmacist.