Medication errors « Medical-Legal Topics

Archive for the ‘Medication errors’ Category

What’s a medical error? Part 2 by Pat Iyer

Monday, July 26th, 2010

I was talking to my son and his girlfriend about medical errors and he asked me to define them. Here are some more cases we have handled.

* the oncology patient who suffered from a large extravasation of a chemotherapeutic drug;
* the patient who fell off the operating room table because the nurse did not apply safety straps;
* the patient whose swollen leg was not reported to the physician on the day of discharge, and who died of a pulmonary embolism shortly after discharge
* the man who jumped through a window because the nurse did not recognize the need to start one to one supervision
* the surgical patient diagnosed with a retained sponge despite the “correct” sponge count;
* the nursing home patient scalded in a bathtub;
* the psychiatric patient who had a history of suicidal ideation and attempts, who was unmonitored, left the hospital, and hung himself in the nearby woods;
* the pediatric patient who went into respiratory distress and whose home care nurse asked his father to come home instead of following directions to call 911;
* the nursing home patient who fractured two hips after being dropped out of a hydraulic lift by a nursing assistant, who did not report the incident;
* the postoperative woman who experienced intra-abdominal hemorrhage and subsequent shock that went undetected by the Post Anesthesia Care Unit nurse.
* untold numbers of pressure sore cases

What are these?

Tags: medical errors, Medical malpractice, nursing errors, Nursing malpractice
Posted in Legal nurse consulting, Medication errors, Nursing malpractice, medical errors | No Comments »

Pat Iyer’s Dirty Dozen Tips for Detecting Altered Medical Records Part 2

Wednesday, June 23rd, 2010

• Compare the nursery records generated at birth with those sent to the hospital to which the baby is transferred.
• Review the copies of hospital records found within a physician’s office records with those supplied by the hospital.
• In most hospitals, the mother’s labor and delivery record is normally copied and placed into the newborn’s chart. The copy from the mother’s chart must be closely compared with the copy from the newborn’s chart in order to see if there are any added additions to a set of records.
• Often, copies of a record are supplied to others in the ordinary course of treatment long before a problem or an attorney appears on the scene. The record examiner should not assume that the records supplied in discovery are identical to the ones supplied to others before a problem manifested itself. It is not unusual for a doctor referring a patient to a specialist to send a copy of the patient’s chart to the consulting doctor. Likewise, when a patient changes providers, a copy of the first doctor’s chart is sometimes sent to the subsequent treating doctor. These records need to be closely compared to see if there are any additions.
• Compare the letters and reports written by physicians when they are found in more than one set of records. Are the letters identical or does one set of records contain fewer or different reports?
• Compare the set of records obtained by the plaintiff prior to litigation with the set provided after the plaintiff’s attorney requested the records.
• Compare the set of records obtained early in litigation with those obtained shortly before resolution of a claim.
• Compare a set of records supplied to the plaintiff with those supplied to a regulatory agency.
• Observe for new entries added to later copies of the record, or pages that are missing from the first set of records. Look for additional pages that were not supplied with the first request for records.
• Look for a stamp or mark (usually on a face sheet) that indicates that the chart was kept under the control of the Risk Management Department or the Health Information Management Director’s office. This indicates that restricted access to the chart was in place. This has likely occurred because of an unexpected outcome or a suspicion of wrong doing.
• Note descriptions of the patient that may reveal antagonism between the patient and staff. A bad clinical outcome may lead to the temptation to alter records.
• Note finger pointing or blaming of other staff members or professionals after an incident occurred.

Modified from Roy Konray and Pat Iyer, “Tampering with medical Records, in Pat Iyer and Barbara Levin (Editors) Medical Legal Aspects of Medical Records, released in March 2010, for more tips at www.medleague.com.

What are these?

Tags: altered medical records, spoliation of evidence, tampering with medical records
Posted in Healthcare Risk Management, Legal nurse consulting, Medical records, Medication errors, Nursing malpractice, Tampering with evidence, Trial lawyer skills, medical errors | No Comments »

Prescription drug overdoses on the rise in U.S.

Monday, June 7th, 2010

by Megan Brooks
(Reuters Health) – More and more Americans are landing in the hospital due to poisoning by powerful prescription painkillers, sedatives and tranquilizers, according to a report released American Journal of Preventive Medicine, April 2010. City-living middle-aged women seem particularly vulnerable.
People have seen the headlines related to Heath Ledger, Michael Jackson, Anna Nicole Smith and they think that’s tragic but maybe contained to Hollywood,” Dr. Jeffrey H. Coben of West Virginia University School of Medicine in Morgantown told Reuters Health. “But the fact of the matter is we are seeing, across the country, very significant increases in serious overdoses associated with these prescription drugs,” Coben warned.

Between 1999 and 2006, US hospital admissions due to poisoning by prescription opioids, sedatives and tranquilizers rose from approximately 43,000 to about 71,000. That increase of 65 percent is about double the increase observed in hospitalizations for poisoning by other drugs and medicines, Coben and colleagues found.

Opioids — examples include morphine, methadone, OxyContin and the active ingredient in Percocet — are powerful narcotic painkillers that can be habit-forming. Some examples of sedatives or tranquilizers include Valium, Xanax, and Ativan.

What’s behind the rise in poisoning by prescription painkillers, sedatives and tranquilizers? “There is not any single cause,” Coben said. “There is increasing availability of powerful prescription drugs in the community and attitudes toward their use tend to be different than attitudes toward using other drugs, especially among young people, who report that prescription drugs are easy to obtain, and they think they are less addictive and less dangerous than street drugs like heroin and cocaine.”
Read more

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Tags: drug overdose, Medication errors, medication overdoses, narcotics, opioid overdose
Posted in Damages, Medication errors, Patient safety, medical errors | No Comments »

Common Errors of Pharmacy Technicians – Guest Post by Ashley Jones

Wednesday, June 2nd, 2010

Medications save lives, but they do so only when they’re taken correctly – by the right patient, who takes the right medicine, at the right time, in the right dosage, by the right route, and for the right amount of time. According to the National Patient Safety Foundation, of the 3 billion prescriptions that are filled, as many as 30 million dispensing errors occur. While some of them are not even noticed, others can have serious consequences, even resulting in death at times. The most common pharmacy errors occur when:

• Pharmacy technicians hand out the wrong prescriptions to patients – they get the names wrong, which means the entire set of medicines is wrong. (Pat was once given pills for another patient with the same last name. The technician did not ask for her first name.) And when patients fail to check the drugs they’ve been given and follow the prescription blindly without even looking at the name, it spells disaster in the making.
• Overworked and negligent pharmacy technicians give out the wrong drug because they don’t read the prescription carefully. This could cause serious consequences if the patient is allergic to the new drug or if it worsens their symptoms and causes them to become more ill.
• Pharmacists and technicians substitute one drug for another without checking with the doctor who prescribed the drug. This could lead to complications because the pharmacist is assuming that he/she is qualified to make the switch.
• They give out drugs that are past their expiration dates and which could either cause harm or not effect a cure since they are worthless past a certain date.
• Pat adds: They can misinterpret handwriting and fill the prescription with the wrong medication.

Errors can have profound consequences for the pharmacists who supervise technicians. A former Ohio pharmacist pled no contest to involuntary manslaughter of a 2-year-old child who died in 2006 as a result of a chemotherapy compounding error. The pharmacy board revoked the pharmacist’s license, and a grand jury indicted him on charges of reckless homicide and involuntary manslaughter. The pharmacist faced up to 5 years in prison. Prosecutors held the pharmacist responsible for the toddler’s death because he oversaw the preparation of her chemotherapy. The child had undergone surgeries and four rounds of chemotherapy to treat a curable malignant tumor at the base of her spine. She was supposed to receive her last dose of chemotherapy on the day of the error. A pharmacy technician mistakenly prepared the infusion using too much 23.4% sodium chloride. According to a news report, the technician mentioned to the pharmacist that the final preparation didn’t seem right, but the error went unnoticed. The infusion was administered to the child, who died 3 days later.

The Institute for Safe Medication Practices expressed the outrage of many in the patient safety world that this case resulted in criminal charges. Safety experts including ISMP advocate for a fair and just path for individuals involved in adverse events, arguing that punishment simply because the patient was harmed does not serve the public interest. Its potential impact on patient safety is enormous, sending the wrong message to healthcare professionals about the importance of reporting and analyzing errors.

Most of these errors occur when pharmacy technicians and pharmacists are too busy, distracted, and overworked. As patients, we can help minimize pharmacy errors by being vigilant, checking the name on the prescription, double checking the medicines against the prescription, ensuring that the drugs are not past their expiration date, and consulting the doctor before we switch to generic or branded equivalents. Don’t be in a rush because it could be a matter of life and death – take the time to check with your pharmacist if you’re not sure that you’ve been given the right medication or if it looks different from what you’ve been taking so far. It’s your health and your life, and unless you assume responsibility for both, you are equally to blame for the disasters that happen when pharmacy errors occur.

This article is contributed by Ashley M. Jones, who regularly writes on the subject of Pharmacy Technician Certification. She invites your questions, comments at her email address: ashleym.jones643@gmail.com.

What are these?

Tags: drug store errors, medication dispensing errors, Medication errors, pharmacy errors, pharmacy technician errors
Posted in Damages, Medication errors, Patient safety | 2 Comments »

Illegible Medical Records based on a chapter by Peter Berge JD, MPA, PA

Wednesday, December 23rd, 2009

What is the name of the drug?

In 2009, people’s lives still hinge upon correct interpretation of handwritten records. Some handwritten records are virtually, or actually, illegible. The prescription above was written for Femara. Premarin was dispensed and harmed the patient who received it.

Plaintiff’s and defense attorneys and other reviewers should be familiar with state laws or regulations that permit the patient (or her representative) to require the healthcare provider to provide a timely transcription of notes. Defense attorneys are not likely to require transcriptions as they are representing the provider, who (if required) would voluntarily produce them. This can be very helpful in expediting the evaluation of otherwise opaque records in the setting of pretrial investigation. If transcriptions were not obtained during the investigative phase, they should be demanded after suit is filed if there is any doubt as to the interpretation of notations.

Regardless of when transcriptions were created, it is important for plaintiff’s counsel during depositions to verify the accuracy of the transcription. It is surprisingly common to find errors in transcription, especially when it turns out that opposing counsel provided the document without verifying the content with the witness.

Defense counsel will often have the advantage of direct access to defendants for assistance in deciphering medical records, except when dealing with the records of individuals with separate counsel. When in doubt, it is prudent to have the client interpret any handwritten notations of questionable legibility. There will be times, however, when the healthcare provider has no more idea of what the note says than the attorney does. While computerized records have some flaws, they eliminate guessing with people’s lives.

Modified from Peter Berge, JD, MPA, PA. “Attorney Use of Medical Records in a Medical Malpractice Case”, from Patricia Iyer and Barbara Levin, Medical Legal Aspects of Medical Records, Second Edition, 2010.

Read more about Med League’s services in medical record analysis.

What are these?

Tags: illegible medical handwriting, incorrect prescription, transcription of medical records
Posted in Communication skills, Legal nurse consulting, Medical malpractice, Medical records, Medication errors, Trial lawyer skills, medical errors | No Comments »

Use of Technology to Save Time by Pat Iyer

Monday, October 5th, 2009

analog devices

Consider how much technology has changed our personal lives. Would we go out without a cell phone? Would we use a travel agent to make flight arrangements? Would we go to the bank to transfer money when we could do so on line? I realized just how much technology affects us when I described the usefulness of OneNote, a Microsoft program, to one of my 26-year-old son’s friends. OneNote enables you to set up sections of notebooks and collect the stray bits of information that drift into your life. My son’s friend was grateful to know there was a digital solution for collecting and organizing data. He said, with a look of horror, that before I told him about One Note, he had been considering “going analog”. It took me a few seconds to realize he was discussing what was to him the most archaic of practices- writing something with a pen.

Nurses are relying increasingly on mobile applications as patient safety and productivity tools, a recent survey showed. “Nurses can quickly look up clinical information on their mobile device right at the patient’s bedside, which helps reduce medication errors and save precious time,” Snyder said. Pam Davis, RN, program director for Centennial Medical Center’s bariatric surgery product line, agreed. She has been using Epocrates for the past four years, initially as a case manager. In her current position, she provides educational information for her patients. This program can be downloaded for free onto Blackberrys, Iphones, Palm Pilots and Windows Mobile devices.

Instead of hauling out the hefty paper drug reference, Davis can search for updated medication information “at her fingertips,” she said. Davis is not alone. More than half of the survey respondents noted they look up drug or disease information on their mobile devices during patient consultations. “Technology makes the processes more efficient,” Davis said. “It makes encounters with patients more effective.” Forty-eight percent of respondents said they have saved more than 30 minutes per day using Epocrates’ drug formulary and reference. Using a mobile application has reduced the time spent on labor-intensive paper charting, Davis said. Davis said that Nashville-based Centennial Medical Center has felt the constraints of the nursing shortage, although the health system has not had to lay off any nurses because of the economic recession. Having health IT has helped nurses do more with less, she said. If nurses are fully trained and the technology is utilized appropriately, mobile device applications are “definitely a time saver,” she said.

What are these?

Tags: healthcare technology
Posted in Medication errors, Patient safety, medical errors | No Comments »

How a medical malpractice suit can make a difference by Pat Iyer

Thursday, September 10th, 2009

The story of Josie King

Why do people file medical malpractice suits? One reason is to get answers about what happened to result in the injury. Another is to prevent the same thing from happening to another person. Although risk managers, practitioners, and administrators may make changes after a bad outcome has occurred, it is not often that the plaintiff gets the satisfaction of knowing that. It is even rarer the terms of a settlement to solidify a plan to share the details of a medical tragedy.

A recent Oregon case shows the power of sharing a lesson that will protect other patients. The plaintiff was an 8-month-old infant who entered a hospital for removal of a cyst that extended through his nose to his brain. The surgery was without complications. After surgery, the infant had fevers, pneumonia, and showed signs of a possible cerebral spinal fluid leak. The discharging physician was a first year resident; the attending neurosurgeon did not see the infant on the day he was discharged. Eight hours after discharge, the infant was taken to the emergency department of another hospital because he was vomiting and lethargic. The emergency department physician called the defendant hospital and was advised that the infant was probably having a medication reaction. The parents returned eleven hours later, when their child was profoundly ill. There was no clear evidence of a systemic infection and possible brain damage.

The infant was emergently transported back to the defendant hospital. He was diagnosed with meningitis, brain damage, and organ failure and suffered a stroke. He requires a ventilator twelve to twenty hours a day, is tube fed, and without effective use of his legs or left arm. He is profoundly developmentally delayed and does not talk. A $12.2 million settlement was reached. The hospital also committed to use the case as a teaching example for its residents for the next ten years and to provide certification of this to the plaintiff’s parents each year from the president of the university.

Source: Lewis Laska, “Infant discharged following brain surgery without being seen by anyone other than junior resident”, Medical Malpractice Verdicts, Settlements, and Experts, February 2009, page 19

The power of sharing the lessons learned from a tragedy of this nature is huge. Unfortunately, it is rare for plaintiffs to achieve this kind of gain. I can think of another case – one we handled at Med League-in which this occurred. I was involved in a Philadelphia case of a young man who developed leg pain and shortness of breath on the day of discharge. The nurse did not inform the physicians, and the man was discharged via telephone order. He collapsed at home and died from a pulmonary embolism. As part of the settlement, the hospital made a policy that a patient had to be seen in person on the day of discharge. They also agreed to use this case in teaching each group of interns and residents.

Anyone not familiar with the story of Josie King, an 18-month-old child who died as a result of medication error, should visit the Josie King Foundation . I heard Sorrel King, Josie’s mother, talk three years ago. Her story lingers. Sorrel took the settlement money provided by Johns Hopkins, the hospital where the incident occurred, and put it back into patient safety efforts. Her work has saved lives of people all over the world. A new book pictured above, has just been released, which describes her crusade.

The key to educate, change, and inspire healthcare professionals with lessons learned so that deaths and injuries make a difference in daily practice.

What are these?

Tags: Josie King, Medical malpractice, medication error, why people sue
Posted in Damages, Healthcare Risk Management, Medical malpractice, Medication errors, Nursing malpractice, Patient safety | No Comments »

Reducing Distractions is Reducing Medication Errors – by Pat Iyer

Wednesday, August 12th, 2009

The sterile cockpit means no interruptions at critical times

My father was fascinated by airplanes when I was little. I recall going to Idlewild Airport in New Jersey to watch planes land. My father was trained as an aeronautical engineer. Little did I know as a child the lessons of the airline industry would spread to healthcare and set an example for systems to reduce patient errors. Crew or Cockpit Resource Management is a term that began in 1979 as a way of defining ways to reduce pilot error through better use of the crew. The patient safety movement is now taking lessons from the airline industry. The airline industry has defined the sterile cockpit as a place which controls interruptions during critical moments of flight.

Nurses prepare medications in busy hallways of hospitals and nursing homes. It is easy to interrupt and distract a nurse during the critical steps of preparing medications. Some concerned experts in patient safety suggest the use of a vest to be worn by a nurse during medication administration. The bright orange vest says, “Do not disturb.” I first heard about the use of vest when Gary Sculli, a former pilot turned nurse, spoke to the New Jersey chapter of the American Society of Healthcare Risk Management (ASHRM). I have been an ASHRM member for many years.

Nurses at Kaiser South San Francisco Medical Center ordered bright orange, construction-style vests off the Internet, which the nurses thought looked “cheesy.” They also found them hot and resisted sharing them with fellow nurses. “They felt it was demeaning,” said Becky Richards, RN, BSN, MA, adult clinical services director Richards. But of even greater concern, despite education about not interrupting nurses during med passes, the vests seemed to attract attention. The hospital tried again on a renal floor, with separate medication rooms. But again, it just didn’t seem to click. “We were really thinking about abandoning the whole idea, because the nurses did not like it,” Richards said. But when the medication administration data came in at the end of the year, the hospital found that during the four and five months after the pilot finished, those two units combined had a 47 percent decrease in errors. The units had not done anything else to reduce errors, just the education about no distractions and the vests.

“At that point we knew we could not turn our backs on our patients,” Richards said. The quality forum nurses tweaked the program, finding more attractive neon yellow vests and reaching out to the medical staff, housekeeping and other departments for support. Kaiser South San Francisco kicked off the new program hospital-wide in April 2007, with the exception of oncology, which refused to participate, writing letters and signing a petition. The hospital decided not to play hardball.

“We were blown away in May. The hospital experienced a 20 percent decrease in medication errors, even though one unit refused to participate,” Richards said. “And that was the only unit that experienced an increase from their previous month’s error rate.”
Source: Decreasing Disruptions Reduces Medication Errors – NurseZone

This report verifies the importance of creating a safer environment for preparing medications. Controlling interruptions and eliminating distractions saves lives.

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Tags: crew resource management, CRM, medical errors, Medication errors, Patient safety, sterile cockpit
Posted in Medical malpractice, Medication errors, Nursing malpractice, Patient safety | 1 Comment »

Michael Jackson: A Demerol Death? by Pat Iyer

Monday, June 29th, 2009

Michael Jackson- Demerol Overdose?

Reports state Jackson stopped breathing shortly after receiving an injection of Demerol. Attempts to resuscitate him were not successful. Was it the combination of medications or the Demerol which caused him to stop breathing? Toxicology reports are pending.

Recent reports reveal that Michael Jackson took an unusual combination of drugs:

Demerol and Vistaril twice a day- Demerol is a pain reliever, and Vistaril potentiates or accentuates the effects of Demerol.
Dilaudid 3 mg twice a day- Dilaudid is one of the strongest narcotics on the market.
Vicodin- an oral narcotic
Prozac 20 mg –antidepressant
Zoloft -antidepressant
Xanax -treats panic or anxiety disorders
Ritalin -for attention disorders
Prilosec-reduces stomach acid

It is unusual to see a patient taking two antidepressants and even more unusual and dangerous to take three narcotics. The danger lies in the accumulation of the medications in the body. Reports on the Internet also emphasize that the singer had lost weight and was skeletal-thin. The risk of overdose increases as weight loss occurs if the dosage is not also decreased.

Demerol is a narcotic pain reliever that used to be given with regularity in hospitals. (It is still acceptable to use Demerol in the recovery room for shivering.) It has fallen out of favor for a few reasons – there are more effective and safer pain relievers on the market and secondly, it is poorly tolerated by elderly people. Visual hallucinations may occur in this population. I recall my mother telling me that when she received Demerol after surgery when she was in her mid 70s. I advised her to request a different medication. She saw moving figures on the hospital room wallpaper. Days after her last Demerol shot, as she was being driven home, she saw icicles hanging in the sky. Another danger: the metabolites of Demerol can accumulate, and cause oversedation and death.

What you can do as an attorney involved in a medical or nursing malpractice case involving a potential overdose from Demerol (or another narcotic): Look at the weight and age of the patient. Ask a legal nurse consultant to do a timeline. This person will need to review the medication administration records and the narcotic sign out logs to determine how much Demerol the patient was given for pain control. Get a pharmacologist and possibly a toxicologist involved to look at the connection between the Demerol and the death.

I have lectured about the dangers of oversedation. Several years ago I was an expert witness for the plaintiff in a case that revolved around oversedation from Demerol. The case resulted in a settlement for the family of the patient. The article on Med League’s blog includes the actual facts of the overdose.

Susan Hill (fictitious name) was wheeled up to her postoperative medical surgical room at 11:30 AM. Mrs. Hill weighed 120 pounds; she was recovering from a hysterectomy. Her postoperative medications included Demerol (meperidine) 50-100 mg IM every 3-4 hours PRN (as needed), and Phenergan 12.5 mg IV every 6 hours PRN for nausea. The nurse assigned to the patient until 7 PM administered 50 mg of Demerol at 12:30 PM and 100 mg at 2 PM and 5 PM. Phenergan 12.5 mg was given IM at 12:30 PM, 2 PM and 5 PM. The nurse administered Phenergan to potentiate the action of Demerol. Read more.

What are these?

Tags: Demerol, Michael Jackson, Nursing malpractice, overdose, oversedation
Posted in Damages, Legal nurse consulting, Medical malpractice, Medical records, Medication errors, Nursing malpractice, Patient safety | 4 Comments »

Insulin: More than a simple injection by Pat Iyer

Wednesday, April 8th, 2009

Have you litigated cases involving insulin overdoses? Insulin is commonly used to control the blood sugars of juvenile or Type 1 diabetics. It is a mistake to take this seemingly harmless drug for granted. Insulin is one of the most dangerous drugs on the market if administered in an improper amount. It is ordered in units. The “U” in a handwritten order has been misinterpreted as a “0”. Ten-fold overdoses have occurred when handwritten orders have been misinterpreted as 100 units instead of 10 units. A dose of 100 units may critically lower a diabetic’s blood sugar, which if uncorrected, can result in death. The Joint Commission’s National Patient Safety Goals specifically require Joint Commission-accredited hospitals to ban the use of U as an abbreviation because of the risk of it being read as a zero.

Children are at high risk for the ill effects of medication errors- they have little ability to survive a catastrophic medication error. The American Nurses Association and the American Nurses Association/California won an important victory involving administration of insulin to children by unlicensed personnel. The groups obtained a court order to stop the unlawful use of unlicensed personnel to give insulin to California school children. The effort to stop the practice was based on the premise that nurses who provided training and oversight to unlicensed personnel were at risk for disciplinary action by the state board of nursing. The administration of insulin by unlicensed personnel violated the Nursing Practice Act. The judge who issued the opinion in November 2008 stated that the Department of Education did not have concurrent authority over the administration of medications and could not override the Nursing Practice Act.

Source of news report: The American Nurse, November/December 2008

See our Medication Error DVD for more information about the subject.

What are these?

Tags: Medication errors
Posted in Joint Commission, Medication errors, Patient safety | No Comments »

Medical-Legal Topics

Archive for the ‘Medication errors’ Category

What’s a medical error? Part 2 by Pat Iyer

Pat Iyer’s Dirty Dozen Tips for Detecting Altered Medical Records Part 2

Prescription drug overdoses on the rise in U.S.

Common Errors of Pharmacy Technicians – Guest Post by Ashley Jones

Illegible Medical Records based on a chapter by Peter Berge JD, MPA, PA

Use of Technology to Save Time by Pat Iyer

How a medical malpractice suit can make a difference by Pat Iyer

Reducing Distractions is Reducing Medication Errors – by Pat Iyer

Michael Jackson: A Demerol Death? by Pat Iyer

Insulin: More than a simple injection by Pat Iyer

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