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Medication Mistakes Are Common And Can Be Deadly

Dec 21, 2003 | www.presstelegram.com

When an airplane crashes, the public demands to know what went wrong. They also want the problem to be corrected so it won't happen again.

The entire space shuttle program has been grounded since the Columbia tragedy last February. There were thorough investigations to find out what happened, and NASA is being held accountable for preventing such an accident from occurring again.

When it comes to medicine, however, there are rarely investigations. It is relatively unusual for someone to be held accountable for a medication mistake, and there has been little progress on putting fail-safe systems in place to prevent the estimated 60 million medication dispensing errors that occur each year.

Several weeks ago, we heard from a woman whose mother died because she was mistakenly dispensed the hormone estradiol instead of her prescribed blood thinner, Coumadin. The writer wondered if others had experienced similar problems.

We have indeed heard from a number of people concerned about pharmacy errors. One woman on a regular anti-anxiety medicine for panic attacks picked up a refill from the pharmacy without realizing that she had been given a much lower dose. After taking it, she began to sweat and shake and felt terrified. She tried to drive to her daughter's home nearby but was pulled over by the police. When her daughter, an EMT, tried to come to her aid, she was arrested. Fortunately, no one was physically injured due to this pharmacy mistake. Both she and her daughter had records and court fines as a consequence, however, and emotional scars linger.

Another reader reports: "Just this past Saturday, my husband had a prescription filled for nitroglycerin SA 6.5 mg. He has been taking this drug for some years following a heart attack.

''When he started to take the medicine, he noticed the color was different. Upon checking the pharmacy label, which stated 6.5 mg., he discovered that the manufacturer's label underneath stated 9 mg. We returned to the pharmacy to have them checked and, sure enough, the dose was wrong."

A pharmacist chimed in: ''I am a pharmacist for a large retail chain. I am always deeply saddened to learn of a death that was preventable. Pharmacists make mistakes, I admit, but what about patient responsibility? If the patient noticed that the tablets looked different, did she contact the pharmacy and question them?

"In the end, it is the pharmacist's responsibility to make sure that the correct medicine is dispensed. The patient has the right to sue the pharmacy over this unfortunate incident.''

Even though the family can bring a suit, legal action is not the best answer. It would be better by far to set up safeguards to keep people from getting the wrong medication in the first place. As readers know, some mistakes can be lethal.

To avoid taking the wrong medicine, make sure you can read your doctor's prescription. Then make a copy of it before you hand it in at the pharmacy. When you pick the prescription up, check it at the counter to make sure the label corresponds to the prescription. If you have taken the drug before, notice if the pills look different and ask the pharmacist to explain any difference. Double-checking in this way is slow and inconvenient, but it could save your life.


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