pharmacy mistakes - New Jersey Accident and Injury Law Blog

UTAH HIGH SCHOOL HONOR STUDENT IN COMA AFTER PHARMACY ERROR

scott@grossmanjustice.com (Scott Grossman) — Sun, 20 Jul 2008 01:32:31 -0500

Earlier this week a story on ksl.com, a Utah television station, reported that an eighteen-year-old honor student received a potentially lethal dose of oxycodone for strep throat and has been in a coma since April 30. The teen, Jessie Scott of Draper, Utah, was given a teaspoon of concentrated oxycodone hydrochloride for pain due to strep throat, when the actual prescription called for a five-milligram dose. The Wal-Mart pharmacy that filled the prescription, was supposed to dilute the concentrated medication before dispensing it to Jessie, but it failed to do so. Jessie received 20 times’ the prescribed dosage due to Wal-Mart’s negligence. As of a result of the pharmacy’s horrific error, a few hours after taking the lethal dose, Jessie Smith’s organs began to fail, he was placed on a ventilator, and one of his lungs collapsed.

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

Children at Increased Risk of Pharmacy Error in Adult Hospitals

scott@grossmanjustice.com (Scott Grossman) — Wed, 28 May 2008 07:49:28 -0500

As a pharmacy error attorney, I have witnessed first hand many cases where children and adults are given the wrong medication due to medications have similar names and sizes so they are easily confused by pharmacy staff. In addition, children taken to adult hospitals suffer injuries or fatalities because these hospitals carry mostly adult size doses of medication so when a child is treated, their medication is often confused with the appropriate adult size.

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.”

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.

Study Shows Risk of Medication Errors Higher for Hospitalized Children

scott@grossmanjustice.com (Scott Grossman) — Wed, 09 Apr 2008 20:47:57 -0500

The medical journal Pediatrics has released a study that shows that hospitalized children are at a high risk of being overdosed, given the wrong medication or have an adverse reaction. In fact, the study revealed that one out of every 15 hospitalized children has fallen victim to medication errors. It is a heartbreaking, terribly frightening new study. Read FoxNews.com's article about the study.

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.

Southeastern Walgreens Makes Dosage Error For Infant Prescription

scott@grossmanjustice.com (Scott Grossman) — Tue, 11 Dec 2007 21:09:52 -0500

KLTV-7 out of Tyler-Longview, Texas reported today that a Walgreen pharmacy filled a prescription for the antibiotic Augmentin four times the prescribed dosage for a five-month old baby. When the baby's mother gave her daughter the first dosage, the baby was vomiting and was lethargic. The label on the prescription said that the baby was to get two teaspoons twice a day of the antibiotic. The baby's doctor prescribed 1/2 teaspoon twice a day. When the pharmacist was confronted with the error, his response was that they were really busy the night the prescription was filled and "accidents happen." Unbelievable. While the baby will be okay, it's yet another lesson to the prescription consuming public how vigilant we all must be when it comes to our health.

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.

Justice is sought for victim of alleged pharmacy malpractice at Walgreens

scott@grossmanjustice.com (Scott Grossman) — Wed, 24 Oct 2007 20:51:58 -0500

When I read this story, I was horrified by what happened to a newly pregnant St. Louis woman who went to Walgreens to fill a prescription for prenatal vitamins and was instead given a potent chemotherapy drug that killed her unborn child. The woman and her husband filed a lawsuit seeking some form of justice against the powerful pharmacy chain, alleging that Walgreens failed to properly supervise pharmacy personnel who dispensed the medicine, failed to verify the prescription with her physician, and failed to follow appropriate protocol.

The couple alleges in their complaint that she began to feel ill and began vomiting about a month into her pregnancy and assumed it was morning sickness, all the while taking what she thought were the prenatal vitamins. About a month later, she miscarried her baby. It is alleged that her unborn child was killed due to the ingesting of the potent chemotherapy drug. After her miscarriage, she continued to take the chemotherapy drugs (still thinking they were prenatal vitamins) because she believed that the vitamins would prepare her for a subsequent pregnancy. It wasn't until she telephoned Walgreens for a refill that the pharmacist realized the mistake. Please read the full article. I implore you to write in about your own personal stories pertaining to pharmacy mistakes and errors and your opinions about what has happened to this couple.

Victims in New Jersey who suffer serious physical harm from pharmacy related-errors will be denied all recourse should the members of the state legislature prevail in the passage of a bill that claims to help prevent pharmacy errors.

scott@grossmanjustice.com (Scott Grossman) — Sun, 08 Apr 2007 20:32:23 -0500

Citizens of New Jersey, would it shock you to learn that in response to concerns about a dangerous increase in pharmacy-related prescription errors, your state legislature has introduced a bill, which if enacted into law, would preclude all forms of recourse should your pharmacist’s mistake cause you or your loved ones to suffer serious physical injuries.Well it’s hard to believe, but amazingly true: pharmacists would receive total immunity from civil liability for any errors committed resulting in serious harm as long as the error was reported to the New Jersey Board of Pharmacy. Even more astonishing is the likely effect the legislation will have on the large national and regional pharmacy chains- complete insulation from liability for the negligent acts of their pharmacist employees.

]]>In 2003, Auburn University conducted a study of retail community pharmacies and dispensing errors. The study revealed the error rate was nearly one error per 55 prescriptions filled (1.72%). The researchers concluded that, for more than three billion prescriptions dispensed nationwide, 51.5 million pharmacy errors occur annually.Just so we are all on the same page, I will define a pharmacy-related error. A pharmacy -related error occurs when a pharmacist:

dispenses the incorrect medication;
dispenses the incorrect dosage of the correct medication;
dispenses the correct medication with incorrect instructions;
dispenses the incorrect drug quantity and strength; or
fails to take into account known drug allergies or dangerous drug interactions with other medications being taken by a patient.

“The Pharmacy Quality Improvement and Error Prevention Act”(A-1025) was passed in the New Jersey Assembly by an astonishing 76 to 0 vote in March 2006. As of this writing, the measure has been referred to the State Senate Commerce Committee for further consideration.

The bill was originally introduced to the New Jersey Assembly by Assemblyman Jeff Van Drew (District 1). Van Drew, a dentist, sponsored the bill in response to a series of articles printed in The Press of Atlantic City during 2002 that chronicled how patients were harmed by faulty prescriptions caused by improper labeling or dosage, increased pharmacists’ workloads and other mistakes.

"To err is human, but pharmaceutical mistakes pose serious, life-threatening consequences. Pharmaceutical errors should not be shrugged off as trivial, rare occurrences, particularly when dealing with drugs that can stop a heart, trigger allergic reactions, or lead to a patient's death," said Assemblyman Van Drew. See press release dated September 14, 2006. It is important to note that all press releases from NJ Legislators failed to mention any information about the fact that the bill also contains language that would totally limit the rights of all seriously injured victims of pharmacy errors to seek compensation through our civil justice system. Here’s an overview of A-1025(I encourage everyone to link to the bill and read it in its entirety):The bill begins with a discussion of a study that revealed that every year, more than 7,000 Americans die from medication errors and further, that the number of complaints filed with the New Jersey Board of Pharmacy concerning prescription errors has more than doubled in the past eight years. The bill calls for immediate action to reduce the possibility of prescription errors as they may seriously harm New Jersey citizens.I agree whole-heartedly that intervening action is desperately needed in order to reduce pharmacy-related medication errors. With the increase in large retail pharmacy chains charged with generating large corporate profits, overworked pharmacy staffs are at risk of making life-threatening errors in increasing numbers. But my analysis of this bill suggests that public safety is not the driving force behind this legislation that the bill’s sponsors would like us to believe it is. It would seem that surrounding the pharmacy industry in a cloak of secrecy and immunity is the way some legislators believe that the public good will be best served.The bill establishes a 24-member task force called the “New Jersey Task Force on Medication Error Prevention.” Out of the 24 members of this task force, 17 are considered “public members” and the remaining seven members are heads of state agencies, representatives of state medical boards, and the Dean of School of Pharmacy at Rutgers. Eleven of the 17 public members are appointed by the recommendations of representatives of organizations of pharmacies, chain drug stores, pharmaceutical manufacturers, mail service pharmacies and health insurance carriers.The stated purpose of the task force is to provide guidelines to assist the New Jersey Board of Pharmacy in medication error prevention, pharmacy quality improvement, and in the development of consumer education programs. These guidelines also set forth the types of situations in which registered pharmacists would be required to report to the Board when they believe a medication-related error may have occurred.
Under the bill, where a patient has suffered “serious” or “significant harm,” a pharmacist would be required to report the error to the Pharmacy Board. The task force is also charged with considering what constitutes “serious” or “significant harm” and further, what information is required in such report.
The bill also requires pharmacies to establish what is called a “quality improvement program” designed to document, review and assess the medication related-errors for the purpose of minimizing the incidents. This information is potentially valuable for analyzing why, where and how pharmacy errors occur so that measures to prevent if not eliminate errors can be developed in response. But here’s the rub: any and all of the information gathered by a pharmacy’s “quality improvement program” concerning medication-related errors is to be considered privileged and confidential and per the terms of this bill, cannot be released to the public for any purposes. It is only allowed to be reviewed internally. I cannot really think of many other professions where the negligent acts of its brethren can be kept hidden from the public via government sanction.The public is prevented from obtaining knowledge as to whether the pharmacist who regularly fills their prescriptions has a history of committing dispensing errors, because that information is privileged. The State believes this is good for the public; the theory is that it will encourage pharmacy professionals to come forward and admit mistakes, hopefully learn from them and not repeat them. In effect, under the guise of public safety, it is the pharmacist who gets the protection after committing an error, and it is the public who is left out in the cold.And I wonder how we would ever know whether this plan works in reducing dispensing errors if we are not able to gather the data surrounding dispensing errors?If the confidentiality provision of the bill didn’t grab your attention, maybe the total immunity concept will. Check this out:Section 9, subsection c of the bill provides in relevant part that registered pharmacists who reports information to the Board relating to a medication-related error, shall be immune from liability in a civil action for any injury or damages in connection with that medication–related error.My fellow New Jerseyans, it is time to wake up and realize what is going on here. This legislation is designed to create a protected class of people who are immune from liability and who are also allowed to self regulate bad behavior in secret under the guise of protecting the public at large. How would the public ever know if this legislation actually achieves its stated purpose when all of the data is completely sealed off from the public?Regardless of how egregious the medication error or how serious the harm, the victim will be left with absolutely no remedy. He or she is supposed to be content with the fact that the Board shall police itself. Your right to protect yourself from injury by the negligent acts of pharmacies has been stripped away, all in the name of reducing pharmacy error.If the State Legislature were serious about reducing the number of medication related errors it would start by adopting laws that impose restrictions on the number of hours a pharmacist can work during any shift. The demands on the chain pharmacies to maximize corporate profits through an assembly line production outfit ultimately leads to more mistakes and patient harm. “In some retail locations, pharmacists are being asked to work 12 hour shifts, sometimes back to back. Pharmacists are asked to handle 30 prescriptions an hour. That’s two minutes to fill a prescription, counsel a patient, and check for potential drug interactions. Pharmacists are under incredible pressure to crank out prescriptions. It’s no wonder mistakes are being made.” Says Phillip Grauss, a senior pharmacist at Kaiser Pernmanente. See Caremark article.
Some states have taken a meaningful approach to reducing the rate of dispensing errors. In North Carolina, for instance, drugstores are now legally responsible when an overworked pharmacist makes a mistake while filling out more than 150 prescriptions per day. If this bill is made into law, then in New Jersey, chain pharmacies would never be held accountable for the negligence of its pharmacist employee, and this is supposed to be in the interest of protecting the consumers of New Jersey. I wonder how it came to be that this bill sailed through the State Assembly without any public outrage. What corporate interests were really behind the crafting of this legislation? Am I the lone voice of outrage here?[1] Elizabeth Allan Flynn et al, National Observational Study of Prescription Dispensing Accuracy and Safety in 50 Pharmacies, 43(2) J.AM. PHARM. ASSOC. 191-200 (2003). Copyright © 2007 by Law Offices of Scott D. Grossman, LLC.Scott D. Grossman is a New Jersey licensed attorney with a Master’s degree in political science from Rutgers University and a passion for protecting patient and consumer rights.