Yourlawyer.com (Pharmacist Malpractice News)

Drug Database Concerns

Fri, 28 Jul 2006 00:00:00 -0700

Over one-million people a year are harmed by medication errors, and the medical community is scrambling to find a solution. Now a UVa doctor believes he has figured out part of the solution. Dr. Scott Strayer believes drug databases are partly to blame.

His research found that on average it took 109 days to update several known databases about recalled medicines. Research conducted by the Assistant Professor of Family Medicine at UVa shows only two out of 15 popular physician drug databases reported the recall of a popular pain killer the same day it was recalled from the market. It is a pain killer that is to blame for heart related illnesses and even deaths.

"Physicians would use these types of databases to look up the different types of drugs that are available, what the dose is," says Strayer.

Now, if a physician were to prescribe a recalled medication to a patient, they would not be able to get it at the pharmacy, but Strayer says this type of lax behavior can lead to complications. "If a major drugs withdrawal isn’t in there, what else is it missing and we haven’t done follow-up studies to see what else is actually missing but our hypothesis would be that obviously it s missing a lot of other things too that may be as important if not more important."

Drug interactions and adverse side effects are among the things the doctor believes would be incorrect, as well.

Strayer says the databases need to be updated on a day-to-day basis in order for physicians to make the best medical choices for the patient. "It’s important to have that information and have that up to date, it’s absolutely critical."

Strayer has suggested to the board that an alert should be sent out to all the databases as soon as a medication has been recalled. He believes this would help reduce the number of medical error deaths significantly.

Strayer says other reasons for medical errors include Pharmacists misinterpreting doctors’ handwriting, and consumers themselves taking the wrong doses.

CVS/Pharmacy Agrees to Hire Safety Group to Oversee Its Medicine Dispensing Practices after Numerous Prescription Errors

Sat, 11 Feb 2006 00:00:00 -0800

Following complaints of 80 prescription errors in 2005, CVS/Pharmacy, the largest drug chain in Massachusetts, has agreed to be overseen by a non-profit group that will employ unannounced inspections and other monitoring methods to examine how the store fills and dispenses prescriptions.

According to the state Board of Pharmacy, CVS dispensed the wrong prescriptions 62 times in 2005. The chain also accumulated 80 prescription mix-up complaints out of a state-wide total of 148 (54%).

In response to these troublesome allegations, CVS has agreed to hire the Institute of Safe Medication Practices, a non-profit patient safety group, to evaluate its protocols for filling prescriptions.

Presently, the state of Massachusetts only becomes aware of a prescription mix-up when a consumer files a complaint. State Sen. Susan C. Tucker (D-Andover) has filed a bill that would force drug stores to inform the Department of Public Health every time they made the mistake of handing out incorrect prescriptions.

Eventually, Tucker hopes that accurate record keeping will lead to the creation of a Web site that would allow the public to have direct access to a store’s safety record.

Tucker says the prescription errors are not limited to CVS. In fact, a 50 year-old Andover resident spent a day in the hospital and weeks recovering after receiving the wrong heart medication from Brooks Pharmacy.

CVS Probe Finds Prescription Errors

Thu, 09 Feb 2006 00:00:00 -0800

A state investigation of CVS pharmacies confirmed dozens of prescription errors since 2002, including one that sent a 4-year-old girl to the hospital, officials said Thursday.

Other problems identified during onsite inspections included look-alike medications being stocked next to each other, improperly labeled inventory and a poor ratio of pharmacists to support personnel.

None of the 62 verified errors or other problems were fatal, said Jean Pontikas, director of the Department of Public Health Division of Health Professions Licensure.

Under an agreement between CVS and the state Board of Pharmacy, the nonprofit Institute of Safe Medication Practices will monitor the 309 Massachusetts CVS stores with pharmacies for two years and could then recommend improvements.

"All in all, we do think there is safe medication dispensing in Massachusetts. However, there are always opportunities to make things better" Pontikas said.

The Board of Pharmacy began investigating CVS pharmacies in June after receiving dozens of consumer complaints.

The problems occurred since 2002, a period when CVS stores filled about 85 million prescriptions in the state, a CVS representative said.

One case involved a 4-year-old Brockton girl who was hospitalized and hooked up to a heart monitor after her mother was given the wrong medication by a CVS pharmacist in July.

Cyira Gillard was supposed to be taking Clonidine for her hyperactive behavior, but received another man's prescription for Flecainide, which is used to treat irregular heartbeats.

CVS said it will implement new safeguards including signs and consumer handouts on avoiding prescription mistakes.

"The health and safety of our customers is our highest priority," said CVS vice president Papatya Tankut.

Man Says CVS Gave Daughter Wrong Drug

Sun, 01 Jan 2006 00:00:00 -0800

A Raynham, Mass., family is warning people to closely check their prescriptions after a 5-year-old girl received an adult dose of Valium by mistake.

NewsCenter 5's Rhondella Richardson reported that Rick Ferranti's daughter, Kayla, left preschool Friday still complaining of stomach pain. The family is returning to the CVS on Bedford Street in East Bridgewater after learning Thursday night that a pharmacist there gave the 5-year-old girl valium instead of the bladder relaxer she needed after surgery.

Kayla had two doses of liquid Valium.

"She got very hyper, she kept laughing and laughing," Ferranti said.
Click here to find out more!

After another dose, Kayla started to complain that she felt dizzy and her stomach hurt.

"I couldn't stop being silly," she said.

CVS attributed the confusion to the similar spelling of the drug names. The child was given Diazepam, the wrong drug, a liquid Valium. The doctor prescribed Ditropan.

By all accounts, the doctor's prescription was clearly written. When he leaned of the error, the Ferranti's doctor called CVS.

In a statement, CVS noted that its "error rate is well below the industry average, and in fact is declining in Massachusetts."

"You really have to check (your prescription). Don't trust them," said Ferranti.

CVS offered its sincere apology to the family for the mistake. They said they'll put measures in place to prevent a recurrence of the problem. The pharmacist in question will remain on the job during the ongoing investigation.

Prescription Mix-Ups Common

Sun, 18 Dec 2005 00:00:00 -0800

Stop and check those pills and read the label before you leave the pharmacy. Mistakes with medication may happen more often than you think.

In fact, experts report pharmacists; hospitals and other health facilities make thousands of mistakes every month. Two back surgeries sent Annie Jackson to a doctor for pain medication prescriptions she had filled last week.

She decided to read up before taking the new pills and discovered a medicine mix up that Jackson says would not have killed her, but could have made her very ill.

The yellow vial containing 100 mg Effexor was labeled Topomax and the 25 mg Topamax labeled Effexor. So, Jackson called the pharmacist at this Alexandria CVS to report the labeling error.

U.S. Pharmacopeia publishes a study of medication errors and the anonymous reporting system produces startling results. USP advices patients to talk directly with pharmacists and carefully monitor what they are getting. Mistakes can be fatal.

Jackson says only the Topamax name on the manufacturer's bottle helped her catch the pharmacy's blunder.
A spokesman for the CVS Corporation says the company regrets the labeling mistake.

Mike DeAngelis also says steps are being taken to prevent future labeling errors. USP reports staffing shortages, distractions and computer entry errors are among the leading causes of medication mix ups.

Prescription error blamed for Everett teen's illness

Fri, 16 Dec 2005 00:00:00 -0800

In yet another dangerous pharmacy blunder, an Everett teen wound up in a hospital after popping high blood pressure medicine mistakenly put into his bottle of sleeping pills.

The state board of pharmacy is investigating 142 complaints of alleged prescription errors at Bay State pharmacies so far this year, and expects to wrap up its probe next month.

Chris Stopford, 17, whose doctor prescribed him the sleep medication Ambien, took one pill Sunday night and another Monday.

The high school junior took two more pills Tuesday night at the suggestion of his doctor because he was still having trouble sleeping. He took another two pills late Wednesday afternoon to try to get some sleep. “I was real dizzy and I was tired,” said the teen.

His father, Robert Stopford, said his son was shaking and “woozy” so he took a closer look at his medication. He noticed some pills were different in size.

The boy believes he took at least three Lisinopril pills, medication used to treat high blood pressure. “They put a mix of the right and wrong pills in the bottle, little tiny pills that look alike,” the father said. “Why did this happen?”

Robert Stopford rushed the bottle back to the Walgreens in Glendale Square, where a pharmacist told him to call 911.

The teen was taken by ambulance to Whidden Hospital, where he was hooked up to an IV and given blood tests. He was later released but must see a doctor today.

“He’s not feeling well at all,” the elder Stopford said yesterday. “I was a nervous wreck. I don’t want this to happen to anyone else.”

Walgreens referred questions to the corporate office. No one there could be reached yesterday.

Mixing Up Drugs with Similar Names Can Cause Potentially Deadly Medication Errors

Mon, 28 Nov 2005 00:00:00 -0800

As the number of prescription and over-the-counter drugs has steadily increased, so have the medical problems associated with dangerous side-effects and interactions.

One very serious problem caused by the sheer number of drugs, however, is the existence of similar sounding names for drugs that are intended to treat vastly different conditions. These mix-ups can be deadly as a recent case in Massachusetts illustrates.

In September, we reported on the death of an elderly man who entered Brockton Hospital in Boston with bipolar disorder. He was lucid and had no life-threatening illnesses. Unfortunately, four days later he was dead; killed by a massive dose of the wrong medication.

The patient was given 60 times the recommended dose of Librium when he was supposed to have received Lithium.

Even after a nurse discovered the initial mistake, the hospital continued to give the man other antidepressants and sedatives. He also received two doses of antibiotics over six hours late.

The hospital attempted to engage in damage control by claiming telling The Patriot Ledger that autopsy results showed the man had died of pneumonia.

According to a hospital spokesman: "When the error was found the doctor and the patient's family were immediately notified. Brockton Hospital immediately launched an investigation and has taken several steps to ensure that this will not happen again."

The errors started when a pharmacist ordered Librium, a sedative taken for anxiety, for the patient instead of Lithium, which he was the drug actually prescribed for his bipolar disorder.

Amazingly, the pharmacist told investigators that even though he realized his mistake immediately, after failing to reach a nurse by telephone, he “forgot to follow through” on the matter. There was plenty of time in which to correct the mistake since the medication was not administered until the next morning.

While the two drugs have similar sounding names, the safe dosage for each is vastly different. A safe dose of Lithium runs up to 600 milligrams a day. The recommended dose of Librium for elderly people, however, is but 5 milligrams two to four times daily.

Thus, the patient received 300 milligrams of Librium, a full 60 times the safe dose of a drug he wasn’t even supposed to receive.

Another potentially serious mix-up that warrants another review exists between three drugs with similar names but vastly different effects have led to serious health problems. The drugs are:

TOPROL-XL® (metoprolol succinate) – AstraZeneca – a beta blocker used to treat high blood pressure, heart failure, and angina used to treat hypertension, chest pain and some kinds of heart failure.
TOPAMAX® (topiramate) – Ortho-McNeil Neurologics Inc. – used to treat epilepsy and to prevent migraines.
TEGRETOL® (carbamazepine) – Novartis – used to treat some kinds of seizures and trigeminal neuralgia (a nerve disorder that causes stabbing head pain).

The FDA and AstraZeneca, have advised doctors that patients who received the wrong drugs reported recurrences of seizures, hallucinations, and hypertension. At least one suicide attempt was possibly linked to failing to receive the right drug, and at least one patient who erroneously received Toprol-XL experienced a dangerous drop in heart rate.

In addition, a priority educational marketing campaign was launched by Ortho-McNeil Neuologics, Inc., to warn healthcare professionals about the possibility of confusion between its product TOPROL-XL® extended-release tablets and TOPAMAX® tablets.

The FDA and other health authorities have received a number of reports from patients receiving one of the drugs instead of the other. These mix-ups have occurred when prescriptions were written incorrectly, read incorrectly, or labeled incorrectly.

Although taking the wrong medication for a specific health problem is always problematic and may pose serious health consequences, this particular situation is extremely dangerous given the severity of the conditions that both drugs are designed to treat.

Patients with epilepsy can experience seizures if they miss doses of their TOPAMAX® therapy. Patients who are on TOPROL-XL® therapy run the risk of heart attack or experiencing angina if they interrupt their drug therapy.

The companies involved have alerted medical professionals nationwide of the problem by letter. They are also establishing direct contact between national pharmacy chains and state and national pharmacy groups. The companies will also issue recommendations to drug information database managers to create “pop-up” alerts regarding the potential for errors.

Ortho-McNeil Neurologics, Inc. has also offered the following suggestions to physicians: are urged to:

Be alert to the possibility of medication errors in patients prescribed either TOPAMAX® or TOPROL-XL®.
Be aware of the possibility of medication errors in any patients presenting with unexpected signs or symptoms while on TOPAMAX® or TOPROL-XL®.
When either drug is prescribed, confirm the brand and generic names and dosage prescribed on written and oral prescriptions.
When dealing with these drugs in particular, print legible prescriptions that include the brand and generic names, with indication.
Counsel patients specifically about the brand name, indication, and proper use of each medication.

In addition, pharmacists are being urged to:

Separate the two drugs from one another on the stock shelf.
Place the shelf-talker provided in the Dear Pharmacist communication on the stock shelf.
Be sure to confirm the brand and generic names prescribed on written and oral prescriptions when either of these drugs is involved.
Confirm the brand and generic names when communicating the drug names within the pharmacy.
Write full and legible prescriptions for these products and communicate oral prescriptions clearly.
Counsel patients about the brand name, indication, and proper use of each medication.

Drug database content providers are urged to:

Install sound-alike/look-alike name alert warnings for the name pair confusion.
Use "tall man" lettering to highlight the end of each name.
Avoid the use of confusing or non-distinguishing drug mnemonics such as "TOP."
Use brand and generic names when communicating the drug names.

Finally, patients should:

Get printed information about the medication from the pharmacist when picking up a prescription for either drug.
Become better informed about their medications by knowing the brand name of each medication, what the medications looks like, and what side-effects they may experience.
Look at the medication before they take it. If it does not look like what they usually take, they should contact their healthcare professional immediately to find out why.
Keep medications in the original, labeled containers to help identify each pill and follow proper directions.
Ask their healthcare professional for more information if they have any questions about their medications, including the benefits and risks.

Medical professionals who encounter any medication error involving TOPAMAX® should report them immediately to Ortho-McNeil Neurologics, Inc., at 1-800-682-6532, and, if TOPROL-XL® is involved, also to AstraZeneca at 1-800-236-9933.

Woman Sues Rite Aid, Pharmacist Over Prescription Mix-Up

Sat, 29 Oct 2005 00:00:00 -0700

A 51-year-old woman has sued Rite Aid Corp. and one of its pharmacists, saying she got sick and addicted when her prescription for bladder medication was accidentally filled with a narcotic painkiller.

Gwen Taylor, a Kirkland real estate agent, said she missed about six weeks of work because she was nauseous, sweating, shaking, overtired and some days lacking the motivation to get dressed.

The single mom said she never thought it was the medicine making her ill; she thought it resulted from being depressed and overwhelmed. She had recently moved, one of her three teenagers had just gone to the emergency room with a bad case of bronchitis and there was just a lot going on, she said.

"I just thought I was sick," she said Friday. "I was under a lot of stress. I never imagined anything like that was possible, so it never crossed my mind."

Taylor went to a Rite Aid pharmacy in Kirkland on May 17 to fill a prescription for oxybutynin to treat an overactive bladder. The pharmacist, identified in a King County Superior Court complaint filed Thursday as Amy Tong, gave her a bottle labeled "oxycodone 5 mg," with instructions to take one pill three to four times daily, Taylor said.

The oxybutynin was supposed to be taken as needed.

Taylor said she had never heard of oxycodone, knew her medication which she had never taken before was called "oxy-something," and assumed it was the correct drug. And actually, since one side effect of the narcotic is reduced urination, it worked, she said.

Taylor said she's extremely sensitive to painkillers, and can only remember taking prescription painkillers twice in her life — once in the early '90s, and once in February 2004.

Taylor said she didn't always take the oxycodone as directed because of her sickness. Sometimes, she said, she wound up driving her children and their friends around while high: though the bottle correctly identified the contents as oxycodone, it carried no warnings about driving or operating machinery.

Taylor said she realized it was the medicine making her sick only when she went into a different Rite Aid for a refill on June 14. A pharmacist there noticed she had been taking the wrong medicine. Taylor's nurse practitioner prescribed her a weaning course of oxycodone for the next few weeks to help with withdrawal; even the lesser dosage made her too sick to work.

A pharmacist who answered the phone at the Kirkland Rite Aid directed calls to a corporate spokeswoman for Harrisburg, Pa.-based Rite Aid, who said only: "We have not yet seen the lawsuit. However, the press release is inaccurate and a misrepresentation of the facts."

Tong, the pharmacist named in the complaint, did not have a published telephone number and could not immediately be reached for comment.

Steven Saxe, executive director of the state Board of Pharmacy, said no one has ever lodged a complaint against Tong, who is about 30 years old and has been licensed as a pharmacist in Washington since June 2000.

In the past year, the state has received 135 complaints related to improper dispensing of medicine, Saxe said. That includes mislabeling, dispensing without a prescription, dispensing the wrong drug and similar allegations.

The Taylor complaint, which alleged that Rite Aid was negligent in failing to supervise Tong, seeks unspecified damages.

Taylor's lawyer, noted that a shareholder lawsuit filed against Rite Aid in recent years accused the company of understaffing its pharmacies, raising the risk of mistakes.

The Board of Pharmacy does not track complaints by pharmacy, but a computer system upgrade is in the works that would allow it to do so, Saxe said.

Prescription errors "can range from things as simple as legibility of the prescription to simple human error," Saxe said. "There are so many drugs that sound alike and look alike. We try to encourage people to quit using abbreviations, to not use trailing zeros so a 1.0 is not mistaken for a 10, and we tell them to write the purpose of the medication down on the prescription."

AstraZeneca Reports TOPROL-XL Medication Errors

Wed, 28 Sep 2005 00:00:00 -0700

Users of the beta blocker TOPROL-XL, taken for the treatment of conditions such as hypertension and angina pectoris, need to insure that they are receiving the correct medicine from their doctors and pharmacists.

The Food and Drug Administration (FDA), along with TOPROL-XL’s manufacturer, AstraZeneca, notified healthcare professionals and pharmacists this week that they had received reports of medication dispensing or prescribing errors.

TOPROL-XL is being confused with Topamax, indicated for the treatment of epilepsy and migraine prophylaxis, and Tegretol or Tegretol-XR, used for the treatment of seizures. According to letters sent to healthcare professionals and pharmacists, AstraZeneca received reports that TOPROL-XL was incorrectly administered to patients instead of Topamax, Tegretol, or Tegretol-XR, and vice versa, some of them leading to adverse effects.

“Adverse effects have been reported to occur as a result of nonadministration of the intended medication and/or exposure to the wrong medication. In some cases, hospitalization was required. Examples of serious events reported…include recurrence of seizures; return of hallucinations; suicide attempt; and recurrence of hypertension.”

According to the letters, the medication error reports indicated that both verbal and written prescriptions were incorrectly interpreted and/or filled due to the similarity in names between the drugs. Additionally, overlapping strengths between TOPROL-XL and the other drugs, and the fact that they are stocked close to each other in a pharmacy, may have contributed to the errors.

The letters ask healthcare professionals to clearly communicate both oral and written prescriptions for TOPROL-XR, and requests that pharmacists arrange product inventory in a way that helps staff to differentiate between medicines, and to read labels several times to confirm that the correct medication is being dispensed.

FDA warns of risk from mixed-up prescriptions

Wed, 28 Sep 2005 00:00:00 -0700

Doctors and pharmacists have been warned that mix-ups in prescriptions of three drugs with similar names but vastly different effects have led to serious health problems.

The drugs are:

    * Toprol-XL, also known by the generic name metoprolol succinate, which is for treating hypertension, chest pain and some kinds of heart failure. It is manufactured by AstraZeneca.
    * Topamax, also known as topiramate, which is used to treat epilepsy and to prevent migraines. It is made by Ortho-McNeil Neurologics Inc.
    * Tegretol, also known as carbamazepine, which is used to treat some kinds of seizures and trigeminal neuralgia, a nerve disorder that causes stabbing head pain. It is manufactured by Novartis.

In letters to doctors and pharmacists, AstraZeneca asked them to take extra care in prescribing these drugs. The letters were released Tuesday by the Food and Drug Administration.

According to letters from AstraZeneca’s chief medical officer, Glenn J. Gormley, patients who received the wrong drugs reported recurrences of seizures, hallucinations and hypertension.

At least one suicide attempt was possibly linked to failing to receive the right drug, Gormley wrote, and at least one patient who erroneously received Toprol-XL experienced a dangerous drop in heart rate.

Gormley asked doctors to write legible prescriptions that include both the brand and generic names of the drugs, and asked pharmacists to double-check drug names against prescriptions.

The FDA has oversight over drug names during its approval process.

Walgreens Accused of Drug Error

Fri, 23 Sep 2005 00:00:00 -0700

A Chesterton couple sued Walgreens, accusing a local pharmacist of giving their baby the wrong prescription.

The 3-month-old girl was supposed to receive a medication to treat a stomach acid problem, yet instead was given a drug designed to slow an adult's heart rate, according to the suit filed by Mark and Karen Titcomb.

The error caused the girl to suffer two to three weeks with severe symptoms of gastroesophageal reflux disorder and potential side effects from the mistaken drug, the suit says.

Her parents also claim to have suffered severe emotional distress by watching their daughter suffer unnecessarily through the family's first Christmas together. The family also incurred medical expenses.

"Walgreens holds itself out as 'The Pharmacy America Trusts,'" according to the suit. "Walgreens and (pharmacist Kimberly) Hager breached that trust and breached their duty".

Walgreens spokesperson Carol Hively said on Thursday the company had not seen the suit and typically does not comment on pending litigation.

Hager could not be reached for comment.

Karen Titcomb said the problems began Dec. 19, 2003, when she filled a prescription for a liquid form of Prevacid at the Chesterton Walgreens store. After returning home, she said she noticed the label on the bottle reflected a higher dosage than she and her husband had been giving her daughter, Ella.

Titcomb said she called the Walgreens store and spoke with Hager, who had filled the prescription. Hager said the dosage on the label was incorrect and directed Titcomb to give the drug to her daughter and return to the store to pick up a correct label, according to the suit.

Titcomb said she picked up the new label on Dec. 21, 2003. While packing to leave town for the Christmas holidays the following day, Titcomb said she received an urgent call from Hager telling her the child had been given the wrong drug and to take the baby to a doctor's office.

Titcomb said she was told her daughter had been given the drug Amiodarone, which is not approved for use by infants and children. The child had been given four dosages of the wrong medication, the suit says.

Titcomb said she notified her husband, Mark Titcomb, who rushed back from a business trip in Omaha, Neb.

The suit alleges gross negligence and negligence, and seeks an unspecified amount of money to compensate the Titcombs. The suit also seeks payment from Walgreens and Hager to punish them and dissuade them and others from similar conduct in the future.

Drug Mix-Ups Are On the Rise

Sun, 24 Jul 2005 00:00:00 -0700

When Kathy Lynch picks up a prescription, she carefully looks at the label to make sure it's hers. She also checks the pills dispensed to make sure they match what she's supposed to be getting.

She's not taking any chances, and she's not alone.

Customers are being more vigilant about checking their medications and asking questions in the wake of much-publicized prescription mix-ups.

Locally, a woman called Sandwich police last Sunday when she received the wrong medication from a pharmacist who was noticeably drunk.

The number of reported pharmacy complaints is up dramatically this year. There have been 84 so far, up from 64 for the entire year in 2003.

Three of the complaints are against CVS stores in Hyannis, Centerville and Marstons Mills and all concern errors filling prescriptions, according to Jean Pontikas, director of the state licensing board. There are no other complaints pending against pharmacies on Cape Cod.

To put the overall number of complaints in perspective, more than 80 million prescriptions were filled in Massachusetts last year.

''Pharmacists are expected to be 100 percent right, 100 percent of the time and that's a lot to ask of someone,'' says Vinny Duarte, owner of Adams Pharmacy, an independent drugstore in Provincetown. ''Someone once told me, 'Doctors bury their mistakes, pharmacists pay for theirs.'''

Michael DeAngelis, a spokesman for CVS, says the chain's error rate is actually down, even if it's profile is up because of recent television reports highlighting mistakes.

''I should point out 40 million prescriptions were filled by CVS in Massachusetts last year,'' he says. The Rhode Island-based chain, with dozens of stores across the Cape, is cooperating with the state-probe. The chain invests millions in pharmacy technology to cut down on potential mistakes.

''No process is completely immune from human errors,'' DeAngelis said.

New regulations

CVS is taking the complaints seriously and says there is no evidence that consumer confidence is shaken.

''We've been in contact with our customer service department and they've seen no spike in calls from people concerned,'' DeAngelis says.

''Pharmacists do an excellent job on a day-to-day basis,'' says Carmelo Cinquonce, executive vice president for the Massachusetts Pharmacies Association. ''Pharmacists fill 83 million prescriptions on a yearly basis in Massachusetts.''

But he says there's no question recent media attention could damage consumer trust.

Duarte says it's important for consumers to be educated on what it is they're taking and for what reason. Too often, customers don't know. He says people who take multiple medications should write them on an index card and keep them in a wallet or pocketbook, especially if they're headed on vacation.

At chain pharmacies, which now dominate the landscape, the chance of errors is magnified by the ''tremendous volume,'' Duarte says.

Another matter of concern is a shortage of pharmacists. It's not a severe problem in Massachusetts, according to Cinquonce, but in some parts of the country - most notably North Carolina - pharmacies have had to shut down.

Prescription errors have led to new regulations that require all pharmacies to create a continuing quality improvement program by December, Pontikas says. Those regulations will require pharmacists to document errors, do an internal investigation and propose ways to fix the problem. The state will conduct an independent probe.

The state board inspects pharmacies if it receives a complaint, but also does surprise visits, Pontikas says. With new regulations going into effect, the state will be doing even more on-site visits.

''The system is a safe one,'' she says.

A matter of trust

Jean Sears, director of the Brewster Council on Aging, says seniors need to be able to trust pharmacists. She knows of one senior who takes 17 medications, and he can't possibly keep track of them all.

''These people rely on pharmacists to tell them they've been given the right thing,'' Sears says. ''They can't figure these things out.''

Cinquonce says the pharmacist is there to help, no matter how busy he or she looks.

''Consumers need to establish a relationship with a pharmacist,'' he says. ''They should ask questions and know what the drug is for and what the side effects are.''

Sedell's customer Sean Cavanaugh says he suffered a prescription mix-up at another pharmacy.

He was able to deal with the mistake on his own. He says he likes using Sedell's and will continue in the future, despite last week's incident.

''They've dealt with the issue,'' he said. ''It could happen anywhere.''

The pharmacist, Frederick C. Beal, 51, of Lakeville, was taken into protective custody after he blew a 0.18 on a portable Breathalyzer machine twice the legal limit for someone driving a car. He was slurring his words and was unsteady on his feet when police arrived. He was fired by Sedell's and surrendered his license to issue prescriptions on Monday.

''I thank the customer because if that customer had left and he remained on the bench something tragic could have happened,'' says Sandy Sedell, owner of Sedell's Pharmacy, which has three other stores off-Cape.

Lynch, for one, says she plans to continue taking matters into her own hands in the wake of the Sedell's incident and other pharmacy problems.

''It's going to make me look at the pills and look at the labels to make sure they're for the right person and they're the right pills,'' she said.

Baby's Prescription Was Four Times Recommended

Mon, 23 May 2005 00:00:00 -0700

A new Omaha mother wants to warn parents about a mistake made on her infant's prescription at a local pharmacy. It made her daughter sick.

Trisha Jones said her 2-month-old daughter, Zoey, had surgery to relieve acid reflux, but after surgery, her daughter continued to suffer.

"She didn't get better, and she cried and cried and cried, so I called the doctor," Jones said.

The doctor's office said it could see Zoey the following day. In the meantime, the office called in a prescription for Zantac.

"I said, 'Well, I have some.' She said, 'How much are you giving her?' 'Three-fourths of a teaspoon like the bottle says.' She said, 'That's way too much.' That's how we figured out she was being overdosed," Jones said.

Zoey was supposed to be getting three-quarters of a milliliter of the medicine. The bottle said to give her three-quarters of a teaspoon nearly four times too much.

"It's horrible. You can't trust your pharmacist," Jones said.

The prescription was filled at the Walgreens at 50th and Center streets. Walgreens' corporate communications released a statement about the mistake: "Errors are rare and we take them very seriously. We're sorry this occurred, and we apologized to the family. We have a multi-step prescription filling process, with numerous safety checks in each step to reduce the chance of human error. We will investigate what happened with this patient, and what can be done to prevent it from happening again."

Doctors tested Zoey's blood and urine to make sure the medication had not done any damage. Jones said her baby will be OK, but she has this warning for parents: double check your child's prescriptions.

"I just want everybody to know, just because the pharmacy gives it to you, doesn't mean it's right," Jones said.

Jones has filed a complaint with the State Health Department against the Walgreens pharmacy at 50th and Center.

Chemo Overdose Result of Illegible Prescription

Tue, 26 Apr 2005 00:00:00 -0700

It was a doctor's illegible handwritten prescription that triggered a lethal chemotherapy overdose that ended the life of a 41-year-old Redwood City father of three at the San Mateo Medical Center, an investigation has revealed.

The Institute for Safe Medication, in presenting its report on the August 2004 incident to the county Board of Supervisors on Tuesday, spread blame throughout a dysfunctional hospital safety system for the medical error that killed Armando Castellanos. The independent report, commissioned by the board, cited multiple miscommunications by an overworked staff as responsible for the death.

On August 12, 2004, Castellanos was injected with 10 times the proper dosage of a chemotherapy drug 500 mg instead of 50 mg. He received a second 50 mg injection before his severe symptoms of toxic overdose were diagnosed a week later and his family was notified.

Stating that they preferred not to split a settlement with any of the numerous lawyers who had contacted them, the Castellanos' family sent the County Counsel's Office a letter asking for $1 million and a written apology earlier this year. The claim has been turned over to the medical center's malpractice insurer.

The state Pharmacy Board has reprimanded and fined the hospital pharmacist who issued the 500 mg dose. Licensing action by the state Nursing Board against the nurse who administered the injection is still pending.

Some of the chemotherapy safety improvements recommended by the outside investigation have already been made at the hospital.

"Handwritten prescriptions haven't been allowed since the accident. They all have to be entered into the computer now," said Dave Hook, spokesman for the San Mateo Medical Center. "We put in a stop the line' policy, where anybody with a question about medication can halt the process."

However, some of the costlier technological safeguards also recommended by the investigators may prove too expensive for the county to continue operating its 2-year-old chemotherapy clinic.

"We're researching whether it might be a cost-benefit advantage to contract out
the chemotherapy to another hospital in the county," said Supervisor Jerry Hill, who chairs the medical center board.

At Tuesday's supervisors meeting, board members were also supposed to consider a whistle-blower ordinance that would require prompt reporting of any possible medical errors at the county hospital. However, decision on the ordinance was postponed until the board's May 17 meeting.

"We want to make the language as specific as possible on what needs to be reported to the supervisors and the hospital administration and the timing,"Hill said.

Pharmacy Mix-Up Spotlights Errors

Thu, 20 Jan 2005 00:00:00 -0800

Christine Miller took one pill and said she soon felt an indescribable sensation she tried to shake off. When she checked the paperwork that accompanied her prescription, it said she had been given the heart medication Digitek and not the antibiotic Zithromax her doctor had prescribed. The prescription she had taken Jan. 14 was for another Miller, a 65-year-old man.

Christine Miller, who is 52 and visually impaired, called a poison control center the same day she took the medicine and read the paperwork. The center told her to go to the emergency room.

After she hung up with the center, an employee from Rite Aid in Bristol called to apologize for the mix-up.

Miller, of Bristol Township, went to Lower Bucks Hospital and got a blood test and checkup; she said she was fine and suffered no adverse effects from the pill. She also returned to Rite Aid and picked up the correct prescription.

The Rite Aid Corp. Tuesday acknowledged the error. The person who handed Miller the prescription Friday was either a pharmacist or an assistant who didn't verify her name and address, a company spokeswoman said. The spokeswoman wouldn't give specifics as to the incident, however.

Rite Aid and many other pharmacies rely on computers, bar-coded labels and automation to help the pharmacist dispense prescriptions accurately. Still, mistakes do happen when humans fail to follow company procedures, corporate spokeswoman Jody Cook said, referring to what happened to Miller.

"An associate was not diligent in checking the name and the address," Cook said, adding that the staff at the Rite Aid on Pond Street in Bristol has been retrained. "We're very happy that no one was hurt."

Cook said the Bristol pharmacy reported what happened to Rite Aid's corporate offices, which is company policy, but the error most likely wouldn't be reported to the state because it doesn't have to be.

Brian McDonald, a spokesman with the Pennsylvania Department of State, which regulates pharmacies, said prescription errors are tracked through voluntary reporting. There's nothing in the law that says prescription errors have to be reported to the state, McDonald said. That's the case in most states, according to industry experts.

According to the Food and Drug Administration, medication errors kill an average of one person daily and injure 1.3 million annually.

That number was based on a study five years ago that sparked improvements and cut down on prescription errors, said Sherrie Borden, a spokeswoman for the U.S. Pharmacopeial Convention Inc. The nonprofit agency sets standards for medications and promotes their safe use. The organization maintains a confidential database of medication errors for hospitals and healthcare professionals.

"Pharmacies are very aware of what they need to do," she said. "They have checks and balances."

She said the key is for consumers to be more knowledgeable about their health.

The two pharmacists who work at the Rite Aid in Bristol have licenses in "good standing" with the Pennsylvania Department of State's Licensing Bureau. No disciplinary actions were found for either pharmacist, the records show.

The Massachusetts Board of Pharmacy recently studied 51 pharmacists who had committed medication errors. The study reported most of the errors were made in dispensing the incorrect drugs or the incorrect strengths (88 percent). Sixty-three percent of errors were committed with new prescriptions. Forty-five percent were committed with prescriptions handwritten by doctors.

"Too many telephone calls" and an "unusually busy day" were the top two distractions cited by the pharmacists in the study, the board said. In 41 percent of the cases, pharmacists said the mistakes occurred because there weren't enough workers to double-check a prescription, the board said.

A study by the University of London's School of Pharmacy showed most prescription mistakes occurred because of "slips in attention."

The Pennsylvania Board of Pharmacy investigated 700 complaints of "improper dispensing" of prescription drugs from 2000 to 2004. The yearly breakdown: 166 complaints in 2000, 126 complaints in 2001, 122 complaints in 2002, 149 complaints in 2003 and 137 complaints in 2004.

From 2000 to 2004, the state Pharmacy Board disciplined 101 pharmacies and pharmacists for "improper dispensing." The yearly breakdowns: 37 in 2000, 19 in 2001, 18 in 2002, 16 in 2003 and 11 in 2004. During that period, 66 pharmacies and pharmacists paid fines to the state. Nine had their licenses suspended. Three licenses were revoked. Two licenses were voluntarily surrendered.

Study Links Fatal Errors To Pharmacists' Workload

Sat, 08 Jan 2005 00:00:00 -0800

A surge in pharmacist workloads at the beginning of every month may have led to fatal medication errors that have killed more than 6,000 people a year, a study of more than 47 million death certificates found.

That surprising finding is prompting researchers to ask government agencies to consider spreading out social service payments, for pharmacies to increase staffing at the first of the month and for consumers to exercise special care in checking their prescriptions.

At the beginning of the month, there is a sharp increase in government payments to the elderly, sick and poor, resulting in higher traffic at retail pharmacies as lower-income patients fill their prescriptions, according to research published in this month's Pharmacotherapy, the Journal of the American College of Clinical Pharmacy.

"You've got a situation where pharmacists are abnormally busy and it's documented that pharmacists make more errors when they're busy. The two things together prompted us to predict there would be this spike in deaths from medication errors," said David Phillips, a professor of sociology at the University of California. "And indeed, that turned out to be the case."

The study didn't address how the errors occur or precisely who may be committing them.

Pharmacist David Hayes, a professor at the University of Houston's College of Pharmacy who works several times a month at a grocery's pharmacies, said the link sounds plausible, particularly in lower-income neighborhoods with larger Medicaid populations.

"The first of the month is not a pleasant experience. It's very busy," Hayes said. "If you're a pharmacist, you worry more at the end of the day about the things you did during the day at the first of the month, if you're in those areas."

To investigate their theory, lead author Phillips and his colleagues looked at 47.7 million computerized death certificates on a database maintained by the National Center for Health Statistics. They started with 1979 because that is when statisticians began using a special coding system to categorize causes of death, and ended with 2000, the year of the most recent data.

Researchers examined death data including date, cause, location of death, age, gender, years of education and substance abuse status. They used years of education to measure socioeconomic status because a positive correlation has been established between the two.

They focused on deaths resulting from poisoning accidents from drugs. One category, "accidental overdose of drug, wrong drug given or taken in error, and drug taken inadvertently," accounted for nearly all of the deaths.

The researchers found that between 1979 and 2000, fatal medication errors dipped sharply at the end of the month when people may be out of money and can't buy medicine.

At the beginning of the month when social service payments come in fatal errors soared, showing a spike of as much as 25 percent above normal at the beginning of the month, leading to 125,000 deaths in the time frame studied. The increase in fatal medication errors didn't vary by socioeconomic status and wasn't larger for substance abusers than for others.

Identification of the death spike and the search for causes can potentially reduce the number of deaths from medication errors, the researchers said.

Hospital Takes Steps To Avoid Errors

Tue, 05 Oct 2004 00:00:00 -0700

After giving four patients the wrong medication last month, Sarasota Memorial Hospital is trying on several fronts to reduce the chance of repeating those mistakes.

Under one strategy, the public hospital is segregating within its pharmacy high-alert medications that pose a significant risk for side effects even when given properly.

The drug given in error last month, a cardiac medication called epinephrine, falls into that class.

These medications also are being labeled more prominently, both in the containers from which they are drawn and on individual vials.

In addition, nurses are finding themselves drawing more medication from single dose vials at the bedside of patients, relying less on syringes pre-filled in the pharmacy.

Last month's series of mistakes, which surfaced Sept. 10 after a nurse noticed one of the four patients having an unusual reaction, occurred because a pharmacy worker drew the wrong drug and filled syringes with it ahead of time.

"It's best to draw the drug at the time of the administration," said Jan Mauck, Sarasota Memorial's chief nursing officer.

"It could take more time, depending on the process, but it's the safest. And time is not as important as patient safety."

Mauck and two other hospital officials Ed Carthew, chief administrative officer, and Dr. Bruce Fleegler, chief medical officer sat down with the Herald-Tribune on Monday to discuss what they have done following the latest spate of medical errors confirmed this year at Sarasota Memorial.

The hospital's chief executive, Dr. Duncan Finlay, was on vacation this week.

In the mistakes last month, the patients were supposed to get Decadron, a steroid used to decrease inflammation, before they went into surgery. Instead, they got epinephrine, which is designed to boost the heart rate.

Last week, Dr. Bernard Feinberg, the hospital's chief of staff, said the error occurred because the two drugs were packaged in bottles similar in size, color and labeling.

Mistakes involving medications are commonplace, accounting for more than half of all medical errors made at hospitals, according to the Institute for Safe Medication Practices.

Strides are being made to reverse that course.

That organization's for-profit arm is working with the pharmaceutical industry to ensure drug labeling and packaging are clear and unlikely to be confused with another.

Meanwhile, the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO, plans to launch a patient safety initiative next year that specifically addresses how to avoid confusing drugs that look alike or whose names sound alike.

Another issue is that of drug shortages, which cause manufacturers to prepare certain medications in multi-dose vials.

Fleegler said when shortages occur, hospital workers are reluctant to discard partially used multi-dose vials because they don't want to waste the medicine.

Both Decadron and epinephrine come in multi-dose vials, he said.

While hospital pharmacies will always need to compound some drugs, such as those used in chemotherapy, Sarasota Memorial hopes to use more vials prepared for a single use.

"Whenever it can be done, it's being done," Fleegler said. "We'll continue to see that more and more."

In its investigation of the September mistakes, Sarasota Memorial concluded within 48 hours how the problem occurred and what it needed to do to prevent similar mistakes. It plans to use the same time frame for future mistakes that have a high risk of recurring.

The hospital has also contracted with a patient safety expert, Victoria Rich, chief nursing officer at the University of Pennsylvania medical school's hospital. Carthew said Rich is a national speaker on the topic.

"The things we are doing here and the things that we've learned here, we hope, will help other hospitals be safer hospitals," Carthew said.

"This is a national issue, and one all health care organizations need to be focused on."

Unlike in the earlier cases, Sarasota Memorial has consistently declined to comment on the health status of the four patients affected.

Sarasota Memorial has confirmed only that no one died as a result.

When the wrong patient underwent heart catheterization there in March, the administration and medical leaders were quick to point out that the patient was unharmed by the invasive procedure.

In its second confirmed medical error this year, the hospital eventually confirmed that a critically ill patient who was given the wrong blood type in late June died the next day.

On Monday, the trio of hospital officials said that patients in the past have asked that no information be released about them. They declined to say whether that was true for the recent four.

"Our experience has been patients do not want to read about themselves in the newspaper, even without their names attached," Fleegler said.

The employee who erred in the medication mixup, Carthew said, will be disciplined and will receive additional education.

Mauck said the hospital also is developing a policy for disclosing future medical mistakes to the public.

Pharmacist Malpractice Erorr Prescription Drug Mistake Lawyer

Tue, 05 Oct 2004 00:00:00 -0700

Pharmacist Malpractice

The high number of prescriptions filled daily by pharmacists can result in negligent and reckless mistakes. A misfiled prescription has the potential to be deadly. Recent television programs have featured stories on misfiled prescriptions and many patients have discovered that the pill in the container is not what was ordered. As a result these errors are responsible for severe injuries and death to individuals who rely on their pharmacist to ensure the medication they receive is the same as the one their physician prescribed.

Pharmacy experts say a big part of the problem is a shortage of pharmacists. "Right now, the number of pharmacists is growing about 1-2 percent a year and the amount of work that each pharmacy is doing is increasing," says Pharmacist Dave DePersio at Vanderbilt Medical Center1. The frequency in which physicians change out generic and brand name prescriptions is also a contributing factor, as a common drug may have multiple names.

In a study of 500 pharmacist malpractice claims conducted by Pharmacists Mutual Insurance Company, the following types of errors were identified: Wrong Drug Dispensed 52%, Wrong Strength Dispensed 27%, Wrong Directions Given 7.4%, for a total of 86.4% of errors that could have been prevented.

A Pharmacy Today survey (published December 15, 1996) asked, "What could cause dispensing errors?" Of 187 responses from 171 pharmacists and 16 pharmacy paraprofessionals, insufficient filling time and too many distractions were identified as two of the major areas of concern. Ringing telephones and customer questions unrelated to medication were frequent sources of interruption.

Unrealistic workload requirements, inadequate technician assistance, and a non supportive system (with no provision for one person to check the work of another) were also identified as factors that can increase the rate of error. In short, many dispensing errors are caused by stress, distraction, or lack of backup.

Hospital Medications Errors

According to data from a 1999 study funded by the Institute of Medicine medical errors in hospitals cause between 44,000 and 98,000 deaths each year. A report from a healthcare quality ratings company hat was conducted in 2004, determined that from 2002 through 2002 an approximate 195,000 hospital patients died each year as a result of medication errors. Medication slip-ups are a common occurrence in hospitals across the United States.

Why Hospital Medication Errors Occur

Patients given medications at wrong time.
Patients given wrong dosages.
Patients given wrong medications.
Patients do not receive medications at all.
Illegible prescriptions

If you or a loved one have been injured as a result of pharmacist malpratice, please fill out the form at the right for a free case evaluation by a qualified attorney.