Community pharmacist admits fatal medicine mistake

From Management in Practice:
A pharmacist who had worked a 10-hour shift without a break wept in court when it heard an elderly woman collapsed and later died after she gave her the wrong drugs.

The daughter of 72-year-old cancer sufferer Carmel Sheller was given a heart rate reducing drug by Elizabeth Lee, 30, who was working on the busy Tesco counter in Dedworth Road, Windsor.

She was in fact supposed to be collecting the steroid prednisolone for her mother who had been prescribed the drug to treat her wheezing and lung inflammation, the Old Bailey heard.

Ms Lee was working as a locum and was in sole charge of the counter when she made the mistake "under pressure" as two other pharmacists were both on maternity leave. The court heard the mother of two had been working from 9am to 7pm.

After pleading guilty to supplying medicine with a misleading label on the package Ms Lee was given a suspended sentence of three months under a breach of the Medicines Act 1968 - an offence carrying a maximum two-year jail sentence. ...more

Watch out for drug names that look, sound alike

I thought this was worth posting even though some of the drug names are not used in Canada. The message is still relevent. For example, Reminyl's name was unchanged in Canada. Also, Klonopin was named Rivotril in Canada.

From the Associated Press:
Take the generic drug clonidine for high blood pressure? Double-check that you didn't leave the drugstore with Klonopin for seizures, or the gout medicine colchicine.

Mixing up drug names because they look or sound alike — like this trio — is among the most common types of medical mistakes, and it can be deadly. Now new efforts are aiming to stem the confusion, and make patients more aware of the risk.

Nearly 1,500 commonly used drugs have names so similar to at least one other medication that they've already caused mix-ups, says a major study by the U.S. Pharmacopeia, which helps set drug standards and promote patient safety.

Last week the influential group opened a Web-based tool to let consumers and doctors easily check if they're using or prescribing any of these error-prone drugs, and what they might confuse it with. Try to spell or pronounce a few on the site — http://www.usp.org — and it's easy to see how mistakes can happen. Did you mean the painkiller Celebrex or the antidepressant Celexa? ...more

Wrong meds blamed for crash

From Surrey (BC) Now:
Nesta DeRoy, 81, was parking her car in front of a Nissan dealership in South Surrey when she stepped on the gas instead of the brake and plowed into the window, sending people inside scurrying for cover.

DeRoy believes the wrong medication made her drowsy.

She's grateful a cement barricade stopped the car from going further, "otherwise it would have been a big disaster because there were people looking in the showroom."

"I could have killed somebody, I could have killed myself."

Moments before the accident, her friend Julie Mahler, remarked that she looked tired and had asked her if she was feeling all right. Mahler even offered to take over the wheel.

Two days after the accident, DeRoy said she called the pharmacy at Save-On-Foods in Scottsdale Mall to renew her prescription for "hydrochlorothiazide," which helps treat her high blood pressure, and that's when she found out she was given Clonazepam, a sedative.

DeRoy said when she gave the pharmacist the number code on her prescription bottle, he went "kind of quiet" and asked her to repeat it. ...more

Lessons to be learned from methadone controversy, says pharmacist

From the Cape Breton (NS) Post:
It’s relatively uncommon for a complaint filed to the professional body governing Nova Scotia pharmacists to proceed to the hearing stage, its registrar said Tuesday.

Susan Wedlake, registrar with the College of Pharmacists, was commenting on a recent settlement worked out between the college and Glace Bay pharmacists Donald and David Ferguson of Ferguson’s Pharmacy in Glace Bay.

An investigation into how the pharmacy dispenses methadone resulted after Ron Whalen of Glace Bay filed a complaint about the care his son, Robert, received there on the day he died.

Wedlake noted the college can follow different processes in response to a complaint — they can be dismissed, resolved informally, or can go on to investigations committee or to hearing committee.

“(Whalen’s complaint) went all the way through the process . . . it’s not common that complaints end up at the hearings level,” Wedlake said. ...more

Overdose victim’s dad calls for public inquiry

From the Halifax (NS) Chronicle Herald:
Two Glace Bay pharmacists will lose their licences for a week after an investigation found they dispensed methadone improperly.

One man died of an overdose of the drug.

And at least three other patients became ill after taking prescribed methadone prepared at Ferguson’s Pharmacy Ltd. in 2005.

The Nova Scotia College of Pharmacists launched a probe of David and Donald Ferguson after Ron Whalen filed a complaint.

Mr. Whalen’s son, Robert Whalen, 23, died in 2005 of a methadone overdose.

"I’m not very happy at all," Mr. Whalen of Glace Bay said Tuesday.

"The two of them lose their licence for a week and they don’t even have to close down the pharmacy. One guy can go to Florida and the other guy can run the pharmacy for a week and then vice versa." ...more

Too many prescriptions, too few pharmacies

From the Indianapolis Star:
When Tabitha Jones picked up her stepson's medicine at a Walgreens store near Nashville in 2004, she had no way to know the pharmacy was so busy that its manager had asked for more staffing months earlier to "decrease the pharmacist's stress."

She also had no idea the drug Walgreens gave her that day was a steroid never intended for children, and not the blood pressure drug prescribed to treat Trey Jones' hand tremors and hyperactivity. Walgreens refilled the prescription four times, eventually at double the adult dosage, before the error was caught. The 5-year-old not only went into premature puberty but also erupted in rages.

Trey's parents sued Walgreens, fearing the steroid could stunt the boy's growth or cause liver damage. "We don't know what could happen later on down the road," his father, Robert Jones Jr., said in a 2006 pretrial deposition.

Pharmacy chains say they've spent billions of dollars on safety technology and other improvements that have cut their prescription-error rates to a fraction of 1 percent. As aging baby boomers and other Americans increasingly rely on prescription drugs, an Auburn University pharmacy study in 2003 projected the odds of getting a prescription with a serious, health-threatening error at about 1 in 1,000. That could amount to 3.7 million such errors a year, based on 2006 national prescription volume. ...more

Drive-throughs lead to errors, pharmacists say

From the Columbus (OH) Dispatch:
A drive-through window at your neighborhood drugstore can make picking up medications easier, but some pharmacists say the setup can lead to errors.

In a national survey, an Ohio State University researcher found that a number of pharmacists think the extra steps it takes to serve customers at drive-through windows can cause dispensing errors, miscommunication among staff members and delays in filling prescriptions.

With all the tasks being performed at drugstores -- filling prescriptions, checking insurance coverage, calling doctors' offices and answering patients' questions -- pharmacists say drive-through windows add another chance for errors.

"Maybe for banking and fast-food restaurants a drive-through is great, but I think in your health care, it shouldn't be through a window while you're sitting in a car," said Sheryl Szeinbach, an OSU pharmacy professor and the study's lead author. ...more

Busy Pharmacy and Over-Worked Pharmacist is Prescription for Error

Here's an interesting opinion regarding pharmacy safety from an American personal injury lawyer. He raises some good points and there are some good tips for patients as well.

From Injuryboard.com:
Pharmacy error in both the local neighborhood stores and hospital setting is on the rise. The consequences of Pharmacy errors can range from harmless to fatal. More than 100,000 Americans die each year of adverse drug reactions, according to an article in the Journal of The American Medical Association. No one knows for sure how many of those deaths are the direct result of pharmacy/pharmacist's negligence, but we do know that the leading cause for prescription mistake is overworked pharmacists.

Many pharmacies fill over 300 prescriptions a day and some pharmacists are being asked to fill 30 prescriptions an hour and work 12 hour shifts, sometimes back to back. This means that within two minutes the pharmacist must: fill the prescription, check for drug interactions, check for contraindications for use and counsel the patient. It's no wonder mistakes are being made. ...more

How Safe Is Your Prescription?

This is an American article, but I thought I'd include it because I like the part which tells patients what they should do to help pharmacist avoid errors.

From Consumer Affairs:
As an expectant mom, Kendra of Brooklyn, New York wanted the best for herself and her baby. Part of that care was a prenatal vitamin.

“My doctor gave me a prescription for the prenatal vitamin, Primacare One,” wrote Kendra. “I dropped off my prescription at the CVS pharmacy and when I returned to pick up the prescription, I was instead given Prednisone.”

The problem Kendra encountered is one of the most common prescription errors -- the kind that occurs when a pharmacist can’t read the prescription properly. Instead of contacting the authorizing physician to confirm the prescription, the pharmacist plays Russian roulette with someone else’s life. ...more

Report details risks some Canadian patients may face

From Canada.com:
A new analysis by the Canadian Institute for Health Information on patient safety has revealed that while problems developing during treatments or procedures are comparatively rare, some do occur more frequently.

For example, in 2005, one in 10 adults with health problems reported receiving the wrong medication or wrong dose in the previous year, according to the CIHI report — which studied data from 2003 to 2006.

Adverse blood transfusion events are reported much less often — about one in 4,100 cases in 2003.

The report noted in a survey, conducted in 2006, eight per cent of primary care doctors reported that patients had received the wrong drug or dose in the last 12 months.

In 2005, 18 per cent of nurses surveyed reported patients in their care had occasionally or frequently received the wrong medication or dose in the previous year. ...more

Patients survive drug mistake

From the Waterloo (Ont.) Record:
Six people who were sent to hospital this week after a Waterloo pharmacist over-prescribed their methadone treatment were lucky to have survived, say experts who specialize in the drug.

Overdosing on methadone -- a narcotic drug used to treat opiate addicts and severe pain sufferers -- can be fatal. In this case, the six who started showing signs of overdose Monday after taking their prescription from University Pharmacy on King Street in Waterloo were treated at hospital and released. Although the store's pharmacist declined to comment yesterday, police say the patients were immediately contacted and advised to go to hospital once the pharmacist realized the error.

Detectives decided charges will not be laid in the case, said police representative Olaf Heinzel.

The six suffered minor physical complaints, mostly discomfort, police said, before receiving treatment to counteract the overdose.

Dr. Nathan Frank, director of the Kitchener methadone clinic, which treats some 400 patients, said there is not much room for error when dealing with methadone, and the dangers are more pronounced with people whose bodies have not yet developed a tolerance for it. ...more

Doctors' poor penmanship can have deadly results

From the Globe and Mail:
The abysmal handwriting of physicians is the stuff of legend among nurses and pharmacists. But the result - frequent medication errors due to drug names and dosages misread from doctors' chicken scratch - is deadly serious.

New research has driven home just how harmful badly written prescriptions and other transcription errors can be.

The study, published in the journal Health Services Research, shows that having doctors write electronic prescriptions - by typing them into a computer rather than writing them by hand - reduces medication errors by a staggering 66 per cent.

"These medication errors are very painful for doctors, as well as the patients. Nobody wants to make a mistake," said Tatyana Shamliyan, a research associate at the University of Minnesota School of Public Health, and the lead author of the paper.

While poor handwriting is a major issue, it is not the only one, she said. Medication errors can occur because of transcription problems, poor communication, incomplete medical records and drug reactions.What is clear, though, is that a computerized physician order entry (CPOE) system dramatically reduces mistakes. ...more

Fatal chemo overdose prompts Alberta reforms

From CBC News:
An investigation into a fatal chemotherapy overdose has led Alberta to revise procedures for the administration of some cancer drugs.

On Tuesday, the Institute for Safe Medication Practices Canada released its independent report on the death of 43-year-old Denise Melanson last summer at Edmonton's Cross Cancer Institute.

Denise Melanson, 43, died last summer at Edmonton's Cross Cancer Institute.
A pump was supposed to deliver fluorouracil, a drug used to treat tumours, over four days, but it was given to Melanson over four hours, along with another chemotherapy drug, cisplatin. ...more