Articles Posted in Pharmacy Misfill

Recently, a state appellate court issued an opinion addressing whether pharmacies can be responsible to a third-party when the third-party suffers injuries as a result of the pharmacy’s negligence. The court discussed complex third-party liability issues that may affect Maryland car accident victims.

In this case, the pharmacy technician negligently gave a customer an incorrect prescription. The medication is known to cause sudden drops in blood pressure and subsequent cognitive impairments. These symptoms are particularly severe when the person taking the drug does not suffer from what the drug is designed to treat.

The driver was on the medication when he allegedly caused a fatal car accident. The customer’s son settled a lawsuit with the pharmacy, but the other victims sued the chain. The plaintiffs filed a lawsuit based on third-party liability and negligence per se. The court found that under the specific facts of the case, the pharmacy did not owe the third parties a duty of care and that negligence per se was not applicable.

Hospitals often refer to tragedies that should not happen in a medical setting as “never events.” These may include patients dying during routine procedures or major medication errors. Saying that they should not happen does not mean that they do not, unfortunately, and few resources are available to track just how frequently “never events” occur.

Any effort to track this type of event is dependent upon reporting by hospitals and other medical providers, who often have both legal and business reasons to prefer not reporting. Hospitals may wish to keep such information private for fear that it could be used against them in litigation. While this may not be an unreasonable worry, it does nothing to alleviate concerns about public safety. Furthermore, any such information that directly pertains to a claim for medical malpractice should be relevant information available through discovery. It turns out that the discovery process may remain the main method for medical malpractice attorneys to obtain information on specific errors.

Hospitals may also cite fear of losing business as a reason to keep “never event” information private, as people would take their business elsewhere, or they might avoid care entirely. The argument that a patient might forgo care rather than risk seems reasonable to an extent, but the interest in having accurate information seems greater.

Finally, patient privacy laws may prevent reporting of specific information on errors. Privacy protections are available, through which hospitals can submit reports with redacted patient information.

Congress passed the Patient Safety and Quality Improvement Act of 2005 (PSQIA) in order to address some of these concerns, but the law does not directly address the issue of public availability of information. The law encourages hospitals to report dangerous conditions, adverse events, and near misses to a system of patient safety organizations (PSO), also created by this law. It also provides for confidentiality of what it defines as “Patient Safety Work Product.” The definition of Patient Safety Work Product is quite broad, encompassing almost all features of an error report, and disclosure is only permitted in strictly-defined circumstances. These circumstances do not seem to include litigation, except after an extensive process of “nonidentification.” The PSQIA also created a national database that allows information to be shared among the PSO’s, obviously subject to the strict disclosure requirements. However, the PSQIA does not require hospitals to report adverse events to the nearest PSO. All reporting under this law is strictly voluntary

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Police in Maryland have arrested a Reisterstown pharmacist. They are accusing Ketankumar Arvind Patel of illegally selling over 23,000 prescription pills. Authorities say that this amount is equal to almost 28,000 pounds of marijuana or 63 kilograms of cocaine. Federal charges have been filed against the 47-year-old.

In the six-count indictment against him, Patel, an Eldersburg resident, is accused of using his Medicine Shoppe Pharmacy to fill bogus prescriptions for Oxycontin, Xanax, and Percocet. The Drug Enforcement Administration’s Baltimore office noted that these painkillers account for more overdose fatalities a year than cocaine and heroin together.

The regional agency is committed to fighting prescription drug abuse. Officials say they will treat pharmacists like “any other drug dealer.” If convicted on all counts, The Baltimore Sun reports that Patel could be ordered to serve a maximum 86 years in prison. He may also face over $26 million in fines.

This week, pharmacist Eric Cropp pleaded no contest to an involuntary manslaughter charge involving the death of a two-year-old patient in 2006. The toddler, Emily Jerry, died after she was administered an overdose of sodium chloride while undergoing chemotherapy at a hospital.

Cropp made the fatal pharmacy error while working as the supervising pharmacist at a hospital. On February 26, 2006, Cropp neglected to catch the pharmacy technician’s preparation error and properly verify whether the contents and composition of the solution were correct before approving a mix that was 23% salt-based when it should have only been 1%. The technician, Katie Dudash, later testified that she had warned Cropp that she didn’t think the mixture was correct.

Following the medication overdose, Emily slipped into a coma before dying on March 1.

Prosecutor James Gutierrez says that Cropp admitted to the mistake and says that he could have or should have seen the warning signs and caught the deadly mistake. Following the pharmacy misfill incident, another pharmacy hired Cropp, who made 15 more pharmacy errors until his license was revoked.

As part of Cropp’s plea agreement, prosecutors dropped the reckless homicide charge against him. Cropp’s sentencing is scheduled for July 17. He could end up serving a maximum five-year prison sentence.

Pharmacy misfills can be catastrophic for the patients that take the wrong medicine or dosage. This is why it is so important that the pharmacy or the pharmacist supervisor double check a prescription or mix to make sure that the dose and/or medication is correct.

In an unrelated incident in another US state, baby Lindsey Lindberg could have died last month if her mother hadn’t noticed that she gave her the wrong medication more than once because of a labeling error.

Lindsey was born in November with a heart defect. Her mother, Courtney Lindberg, had been giving her a number of prescriptions that she would get filled at a Walgreens. Right before the Lindsey was supposed to undergo open heart surgery, she began to act fussy. It wasn’t until she spit up that Courtney realized that Walgreens had put the correct label for Lindsey’s medication on a bottle containing the wrong medicine.

A 2-year-old. A death. A pharmacist facing jail. What will spur lasting change?, MedCity News, May 14, 2009
Pharmacist Could Get 5 Years For Fatal Chemo Error In Toddler,, May 13, 2009
Mom gives baby wrong drug after labeling error,, May 6, 2009
Related Web Resources:
Unreported Pharmacy Errors, ABC News
20 Tips to Help Prevent Medical Errors in Children,

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US pharmacists filled 3.8 billion prescriptions in 2007. This increase in pharmacy prescriptions—up from 3.3 billion in 2002—means that pharmacists are busier than ever. According to pharmacy owner Paul Lofholm, his pharmacists can fill up to 100 prescriptions a shift.

According to SmartMoney, the busy workload is creating a number of downsides that can affect how well pharmacists do their jobs, which in turn can make them more prone to pharmacy errors. For instance:

1) Pharmacists are stressed out and working too much.
2) This makes them tired, which means they can’t always be 100% focused when doing their jobs.
3) They may have less time to provide counseling about each prescription.
4) They’re more likely to make mistakes. For example, in 2007, there were 433 complaints filed about prescription errors in California.

5) An increase in inventory may mean that pharmacists may not be fully informed about all of the medications that are now available. This can affect any counseling they can provide or prevent them from recognizing potentially dangerous side effects that can result.

Pharmacy errors can be grounds for Maryland personal injury claims or lawsuits if a customer gets injured, sick, or dies because the pharmacist filled the prescription with the wrong medication, neglected to advise the patient of adverse reactions and the patient got sick, or gave the wrong dosage of the right medication or the wrong medication to the a patient.

A 2007 CNN article recommended that patients take proactive steps to avoid becoming the victim of pharmacy mistakes, including:

• Try not to fill your prescription at the start of the month. Because Social Security checks come at the start of the month, more people come in to get their medications at this time. This means pharmacists are busier, which increases the chance of prescription mistakes.

• Open your prescription at the pharmacy and ask the pharmacist to double check that they gave you the correct medicine. If you think they made a mistake, voice your concerns.

10 Things Your Pharmacist Won’t Tell You, SmartMoney
Don’t be a victim of pharmacy errors,, October 30, 2007
Related Web Resource:
Inside a pharmacy where a fatal error occurred, USA Today, February 14, 2008

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Prescription errors are a prevalent problem in the United States that too often leads to serious injuries and deaths. A USA Today investigation reports that corporate policies—particularly with the larger pharmacy chains, such as CVS and Walgreens—can lead to unnecessary pharmacy mistakes:

Too many prescriptions, too few pharmacists. Long shifts and minimal breaks can lead to carelessness, fatigue, and inattention when filling prescriptions.

A reliance on technicians. Technicians lack the training and experience of qualified pharmacists have and are more prone to unknowingly make mistakes.

An emphasis on speed. Providing speedy customer service can sometimes take priority over carefully filling a prescription.

Pharmacist incentive awards. Companies such as CVS and Walgreens provide rewards based on prescription volume.

Counseling gaps. The occasional failure to provide in-person counseling and direction to customers picking up new prescriptions.

In 2003, an Auburn University pharmacy study estimated that the chances of a person experiencing a serious prescription-related error was 1 in 1000. This can add up to a possible 3.7million pharmacy errors annually.

Common Pharmacy Errors Include:

• Filling the right prescription with the wrong medication.
• Filing the prescription correctly but giving it to the wrong customer.
• Not making sure that the customer understands the instructions for how to take the medication.

• Misreading the doctor’s prescription and filling the prescription incorrectly.

Pharmacy errors and prescription misfills can be grounds for personal injury or wrongful death lawsuits if a patient is injured, becomes ill, or dies as a result. In Maryland and Washington D.C., our personal injury attorneyshave successfully handled injury and wrongful death cases caused by pharmacy mistakes. We would be happy to offer you a free consultation to discuss your case.

Speed, high volume can trigger mistakes, USA, February 11, 2008

Related Web Resources:

Don’t be a victim of pharmacy errors,, October 30, 2007
Strategies to Reduce Medication Errors,

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A couple is suing Walgreens for wrongful death. The Missouri couple is claiming that the woman miscarried her baby because a Walgreens pharmacy accidentally gave her a chemotherapy drug instead of the prenatal vitamin that a doctor had prescribed her.

Instead of being given the prenatal vitamin Materna, a Walgreens pharmacy in O’Fallon, Missouri gave her Matulane, which is used to treat Hodgkin’s disease. The Physicians’ Desk Reference and both say that Matulane can cause fetal harm in pregnant women.

Chanda Givens, who was pregnant at the time, suffered skin rashes, nausea, vomiting, vision changes, neurological symptoms, lightheadedness, dizziness, shortness of breath, and chills after taking the drug that she thought was a prenatal vitamin. She took the drug for a few weeks.

When she went to a doctor, a medical exam revealed that the baby was not developing properly. She later miscarried the baby. Her wrongful death lawsuit says that her miscarriage was “a direct and proximate result of the misfill of the prescription for a prenatal vitamin with a potent and toxic chemotherapy drug. Givens and her husband are blaming Walgreens for failing to properly fill the prescription. They say that the pharmacy should have double checked with her doctor as to why a pregnant woman would even take a chemotherapy drug.

The Givens are seeking personal injury damages, including medical costs greater than $75,000 and punitive damages greater than $75,000. The Givens do not want to settle and want to take their wrongful death case to trial.

Pharmacists have a medical responsibility to provide all patients with the proper prescription medication. Giving someone the wrong medication, the wrong dosage of medication, or someone else’s medication can have grave consequences on a person’s health and can lead to a number of serious injuries, including miscarriage, organ damage, strokes, and death.

Common causes for pharmacy misfill errors include pharmacist inexperience, carelessness, negligence, or misreading a prescription note.

Suit faults prescription mistake for miscarriage,, October 17, 2007

Related Web Resources:




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The family of Keith Scofield, a Frederick man who died 20 days after being sold the wrong drug for diabetes at a local Wal-Mart, is suing the retail chain for $50 million in a wrongful death lawsuit. The documents were filed in Frederick County Circuit Court on December 1.

According to the documents, Scofield died on Jan 2, 2006 after taking a prescription that was five times stronger than the over-the-counter dose he had requested at the Guilford Drive Store on December 13. In the complaint, Wal-Mart is being accused of gross negligence related to insulin poisoning. This includes placing the public at risk and failing to properly train pharmacy employees.

Mr. Scofield’s parents and his brother Kraig Scofield are the plaintiffs in the lawsuit. Kraig was with Keith when a when a Wal-Mart employee gave Keith Humulin R (u-500) instead of Humulin R (u-100). The brothers were not aware that they had been given the wrong medication.

“Wal-Mart failed to implement a proper practice for training pharmacists how to execute their duties and their obligations under Maryland law,” Mr. Quinn wrote in the documents. “Wal-Mart had actual knowledge of the employee’s incompetence.”

The complaint goes on to say that the employee’s failure to include a warning with the medicine led to Scofield’s wrongful death.

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