Medication errors are a serious problem, causing over 1 million injuries and 100,000 deaths annually in the US. The elderly and children are most at risk. Common types of errors include administration of the wrong drug or wrong dosage, drug allergic reactions, narcotic overdoses, anticoagulant errors, insulin errors, drug interactions, pharmacy dispensing mistakes, inadequate warnings, infusion pump errors, incorrect pediatric dosages, confusing packaging, similar drug names, and improper abbreviations. Many errors are preventable through diligence and safety practices.

1. Medication Errors - the Annual Toll:
FACTS:
In 2008 - 3.5 Billion Prescriptions were written, filled and dispensed in US
1% error rate or 35 Million “Medication Errors” occurred in Hospitals, SNFs, at
Errors” SNFs,
home
“Medication Errors” cause 1,000,000 serious injuries annually
Errors”
“Medication Errors” cause 100,000 deaths annually
Errors”
More deaths annually in U.S. from Medication Errors than auto accidents and
work place injuries combined
Nearly all medication errors are preventable.
The Elderly and Children are at greatest risk for serious injury due to
medication errors
Source: Institute of Medicine, National Academy of Sciences.
Preventing Medication Errors Report

2. Conventional Wisdom / Statement of the Obvious
Most serious medication errors result from administration of
either:
the wrong drug or medication;
in the wrong dosage;
to the wrong patient;
at the wrong time.
Or a combination of any of all of these events

3. 2 Objectives of this Web Seminar:
Identity 12 specific types of medication errors made daily
in hospitals, pharmacies, nursing homes and in medical
offices and clinics
Provide tips, medical resources and litigation tools
that savvy PI injury attorney can use to recognize,
investigate and successfully (and cost effectively) litigate
and settle these serious injury or death cases.

4. THE TOP 12 LIST :
1. Allergic / Anaphylactic Reactions
2. Narcotic pain medication “over dosage”
3. Anti-coagulant (Coumadin) dosage error
4. Insulin administration error
5. Adverse Medication “Interactions”
6. Pharmacy dispensing errors
7. Inadequate warnings or instructions
8. Drug infusion pump programming error
9. Miscalculation of proper pediatric dosage
10. Confusing drug packaging
11. “Similar Drug Name” Confusion
12. Use of error prone abbreviations

5. 1. Allergic / Anaphylactic Reactions
Physiology of a drug “allergic reaction”
A person may have a genetic predisposition or sensitivity to a
specific medication, or have a limited tolerance
When a person is 1st exposure to a drug to which he/she has a
“sensitivity”, their immune system produces an antibody,
(immunoglobulin E or IgE) which is stored on special cells
When a person is exposed to the drug again, or in amounts in
excess of their tolerance levels, the antibodies can trigger release
of chemicals called “mediators” which can trigger a widespread
systemic reaction to the drug, called an “allergic reaction.”
Most severe reactions can be cardiac, pulmonary or skin reactions
Anaphylactic reaction (shock) severe reaction to a drug to which
a person has an extreme sensitivity

6. Anaphylactic Reaction
Serious allergic reaction - can be life threatening.
Characteristics of anaphylaxis / anaphylactic shock include:
Severe Skin reaction: Hives, itching, redness/flushing, warmth, (S.J.S)
warmth,
Cardiac reaction: Arrest, tachycardia, abnormal cardiac rhythm
Respiratory reaction: SOB, wheezing, throat tightness, tachypnea
Circulatory reaction: Loss of consciousness, syncope (fainting),
due to hypotension (decrease in blood pressure)
Edema / Swelling : Face, tongue, lips, throat, joints, hands, or feet
Most occur within one hour of taking the drug, and many occur within
minutes or even seconds.
Requires immediate examination and treatment in a hospital ER
Medical Tx :
Anti-histamines (Benadryl), steroids (Prednisone), Epinephrine

7. Most Common Drugs Allergies:
Painkillers (analgesics)
Narcotics: morphine, codeine, demerol, hydrocodone,
etc.
NSAIDS (non-steroidal anti-inflamatory drugs)
Aspirin, Ibuprofen, indomethacin
Antibiotics:
Penicillin
Sulfa drugs (Septra, Bactrim)
Erythromycin
Tetracyclicline
Antiseizure medications
Dilantin , Tegretol and others

8. Meritorious Allergic Reaction Cases:
Prescription or administration of drug to which patient has a known or
documented allergy or reaction:
- Patient questionnaire, intake forms: allergies?
- Family Hx of medication allergy or reaction?
- Patient wrist band / Medic-alert bracelet
- Hospital admission forms
- Stickers on office / hospital chart (RTPD - original )
- EMR (electronic medical records)
- Anesthesia record / chart
“Serious injury” requiring hospitalization / extended treatment
“Cross Reactivity” issues:
Brand Name vs. Generic Name issues
– different “inactive ingredients” to which Pt may be allergic

9. 2. Narcotic pain medication “over dosage”
Narcotic pain relievers – “Opioids” include:
Morphine, demerol, codeine, hydrocodone, dilaudid, oxycontin
Among most commonly prescribed medications today
Used to Tx moderate to severe chronic & acute pain
Physiological effects:
Central nervous system depression
Profound respiratory depression
Nausea, vomiting , possible aspiration of emeses
Possible Injuries:
Death
Hypoxic brain injury
Aspiration pneumonia, pulmonary infections

10. Meritorious narcotic “overdose” cases:
- Wrong (excessive) dose administered
- Rx: 10 “mcgs” (micrograms) but 10 “mgs” (milligrams) given
- Rx: “QD” ( 1 x per day), but med given “QID” (4x / day)
- Fentanyl transdermal patch leak
- Symptoms of respiratory distress misinterpreted as pain
response, and RN administered additional narcotic
- Multiple care-givers fill same order ( 3 pain shots in ER)
- Incorrect dosage instructions typed on bottle by pharmacy
technician - “apply 1 patch every 3 hours”
- should have been “ 1 every 3 days”
- Excessive pediatric dosage
- OD due to “Synergestic” multiplier effect of other meds,

11. 3. Coumadin / Heparin Anti-coagulant Dosage Error
Anticoagulants / Anti-Thrombotic Tx prescribed for a variety of
conditions:
Treatment of current DVT, PE, Venous thromboemboism
Cardiac rhythm disturbance: Atrial fibrilation
Prosthetic heart valve
Significant risks of anticoagulants:
If blood level too high (supratheraputic) - significant risk of bleeding
- If blood level too low (subtheraputic) - significant risk of clot/ Pe/ DVT
INR Monitoring required for patients on anticoagulants
Requires regular blood tests “INR” levels
“Target” theraputic range usually 2.0 – 3.5
Often requires frequent / daily dosage adjustments

12. Meritorious Coumadin Error Cases:
MD fails to order INR labs w/ sufficient frequency
Coumadin Clinic failure to promptly communicate INR
levels / dose adjustments to patient, nursing home
(typically w/in 2 days of INR check - phone & Fax)
Failure of health care provider / nursing home to
diligently follow dose adjustment instructions
MD misinterpreting EMR (electronic med record) INR
results and prescribed excessive doses
Pharmacist mis-calculating proper dose adjustments post
INR ( Is Coumadin clinic using proper protocol?)

13. 4. Insulin Administration Errors
Insulin an injectable drug diabetics use to control blood sugar levels
Insulin administration errors are associated with serious risks & complications
Insulin administration errors continue to be common in hospitals and SNFs
Most Common Types of Insulin Administration Errors:
Omission errors / missed dose - leading to hyperglycemia
Improper dose / quantity - leading to either hyper or hypo glycemia
Numerous types of insulin products (~ 23 different brands)
further amplify the potential for errors to occur.
Potential Injuries:
- Diabetic coma / death / cerebral edema / severe neurological injury

14. 5. Adverse Medication “Interactions”
Most drugs are metabolized by enzymes in the liver
Drug “interactions” can occur when one drug interferes with
metabolization of another drug by the liver
This can produce a wide range of adverse reactions:
Renal failure, seizures, cardiac and pulmonary
Many such adverse “interactions” are recognized and catalogued,
charted and tracked by pharmacy and hospital computers
See:
Types of drugs that frequently cause adverse “interactions”:
- Antibiotics: Cipro, Erythromycin
- Anticoagulants: Heparin & Coumadin
- Anticonvulsants: Phenotin, Diazepam
- Cardiac meds: Digoxin,

15. Meritorious Drug Interaction Cases:
Physician/hospital failed to obtain or maintain list of
- Patient’s current medications
- Patient’s past medication reactions (if any)
- Family Hx of any medication reaction/interaction
Physician knowledge deficit re meds most likely to
interact with other meds ( anticonvulsants, antibiotics,
anticoagulants, cardiac meds, insulin)
- Physician or pharmacist fails to check :
- Pocket / iphone / Blackberry reference source Eg. Epocrates
- Computer data base / On line resources for drug interactions

16. 6. Pharmacy Dispensing Errors
From ’00 – ‘10 growth # of drug prescriptions & # of pharmacies
2008 > 3.5 billion prescriptions written & filled in U.S.
More pharmacies, mores pharmacists, increased reliance on
pharmacy technicians for more complex tasks
1% estimated error rate = 350 million errors !!
Out Patient pharmacy error rate higher than In Patient error rate
More Pharmacy Drug Dispensing Errors of every type:
Wrong drug ( confusing drug names)
Wrong patient ( Patient A’s meds given to Patient B)
Wrong dosage instructions ( # of pills to take per day, # of x to take)
Failure to check Pt’s other meds Rx’d for possible interaction
Wrong pills put into bottle with correct label and instructions for
prescribed medication
Wrong instruction label put on pill bottle
Wrong warning / instruction sheet with medication bottle

17. Litigation tips re claims vs. Pharmacies:
All Chain Pharmacies competing for lucrative business
All want to avoid negative publicity and headlines about lawsuits
All want to settle claims expediently and confidentially
All will settle meritorious claims as soon as claim documented
Settlement Strategies:
- Instruct clients to save pills bottles, pills, & warning sheets
- Request All records from Rx’ing MD & Pharmacy
- Request All records & billings from ER, Tx’ing MDs, Hospital, SNF, etc.
- Even “modest” injuries can be worth pursuing
- Consider written report from Pharmacologist re causation and damages
-
- Detailed pre-lit “Demand Letter” will reap solid results

18. 7. Inadequate Instructions & Warnings:
Multiple Sources of Medication Instructions & Warnings to Patients:
Prescribing Physician, NP
Dispensing Pharmacist
Nurses administering medications
Hospital, Surgery Center “Patient Discharge Instructions”
Drug / Medication Labels and Package Inserts
PDR, Medication / Drug Texts & Compendiums
Direct Advertising by drug manufacturer
Internet Sources: Range from excellent to wrong information

19. Basis of “Inadequate” information or warnings:
Confusing, incomplete verbal instructions
Failure to warn of interactions with other meds, OTC, herbs, foods
“Medicalese” – polysyllabic medical words and phrases
ESL – English as second language for many patients
Inconsistent labeling standards
Confusing, Inconsistent dose , administration instructions
Illegible small print on drug / medication inserts

20. Potential Meritorious Cases
MD, Pharmacist, RN, etc. - fails to give any instructions at all
MD, Pharmacist, RN, etc. - gives incomplete or wrong info
“No this medication (Norco) does not contain any .narcotic…”
.narcotic…”
“Even if you have reacted to Septra, this Bactrim is safe for you…”
Septra, you…”
“It is safe to use steroid containing eyedrops for up to 6 months…”
months…”
“This medication is safe for children……..”
children……..”
Wrong warning label, package insert provided to patient
Failure to advise Pt when to stop, discontinue or reduce dose
Failure to provide Pt with contact information for questions
(especially problematic following hospital, surgery center dischages)

21. 8. Drug infusion pump programming error

22. IV Infusion Pumps :
IV Infusion pumps are involved in 1/3 serious med errors
IV medication administration error is 3x more likely to
cause death or serious injury than oral or IM admin
Drug flows directly into blood stream and to critical
organs, with immediate physiological effect
Common programming errors: flow rate, total dosage
Most frequent IV Infusion Pump errors involve:
Narcotic pain medications, Insulin & Anticoagulants
Miscalculation of proper dose, “ free flow” of meds
New “Smart Pump” Programs
More “user friendly software” to reduce errors
More “automatic” warnings re med, pt, dosages, etc.

23. 9. Miscalculation of proper pediatric dosage:
Pediatric medication errors are an enormous problem nationally
Key Factors:
Meds Instructions frequently give: “adult dose” vs. “child’s dose”
“Children” vary so much in weight:
Infant or toddler weight may be fraction of 10 yr olds weight
Lower weight / body mass / intravascular volume means a much narrower
margin of error in correct dosage for “children”
Most drugs - not tested in large #s of children to establish “safe” dosage
Medication errors occur with same frequency in adults and children
Serious injuries or death are 7x more common in children
“Most of serious injuries & deaths prevented if providers wrote orders using
computers that included dose checking.“
Source: (Institute for Safe medication Practices 2002 Report )

24. 10. Confusing Drug Packaging
Example: Lanoxin (Digoxin / Digitalis) powerful cardiac drug
The dropper utilizes "cc" for dosing
The packaging states "mL" for milliliters, also references “mcg” for micrgrams
"mL" mcg”
Confusing for a patient who may be unaware that 1 cc = 1 mL or 1ml = 1000 mcg

25. Confusing Drug Packaging: Children’s Tylenol
Blister package exhibits confusing labeling
Could accidentally double the typical dose
of medication given to small children.
Front of the carton states "medicine per
dose 80 mg,"
Individual blister packs that contain either
one or two
80 mg tablets are all labeled "Children's
Tylenol 80 mg"
Over-the-counter product of potentially
high risk medication given to young
children.

26. 11. “Similar Drug Name” Confusion
In U.S. > 10,000 FDA approved “prescription” drugs
>100,000 OTC “over the counter” medications available
- MANY of these drugs have similar looking / sounding names
- “Similar Drug Name” confusion is frequent cause of the
“wrong drug” being given to a patient by nurse or pharmacy
- Similar sounding name: verbal or telephone order confusion
- Similar looking name: written prescription confusion
- Death or serious injury can result from such confusion
Miscalculation of proper pediatric dosage
-www.ismp.org/Tools/confuseddrugnames.pdf
- 8 page List of “most frequently confused” drug Names > 600 entries
- Allega – Viagra Cedax - Cidex
- Alprazolam – Lorazepam Cozaar – Zocor
- Amicar - Omacar Dynacirc - Dynacin
- Aricept – Aciphex Lunesta - Neulasta
- Benazepril – Benadryl Panalor – Pamelor
- Flowmax – volmax Zantac - Zyrtec

27. 12. Use of error prone abbreviations
Use of “similar looking” abbreviations leads to frequent errors:
Wrong dug: “DPT” – demerol, phenergan, tegretol vs.
- diptheria, pertusses, tetanus
Wrong dosage:
“mg” milligram vs. “mcg” microgram ( 1000 x difference)
Wrong administration schedule
“qd” 1 each day vs. “qid” 4 x per day (4x difference)
Wrong location of administration of medication:
OD, OS, OU R eye, L eye, Each eye
Wrong route / method of drug administration:
IV, IM, IN Intravenous, Intramuscular, Intranasal
Institute for Safe Medication Practices List of error prone
Abbreviations, Symbols and Dose Designations:
http://www.ismp.org/Tools/errorproneabbreviations.pdf

28. RESOURCES: MEDICATION SAFETY WEBSITES
1. Institute for Safe Medication Practices 7. Health Care Choices
www.ismp.org www.healthcarechoices.org
8. Health Grades
2. FDA MedWatch www.healthgrades.com
www.fda.gov/medwatch/index.html
9. Institute for Healthcare Improvement
3. National Center For Patient Safety www.ihi.org/ihi
www.patientsafety.gov
10. P.U.L.S.E. (Persons United Limiting
4. Agency for Healthcare Research and Quality Substandards and Errors in Healthcare)
www.ahrq.gov www.pulseamerica.org
5. Center for Improving Medication 11. Partnership for Patient Safety (P4PS)
Management www.p4ps.org
www.learnaboutrxsafety.org
12. Patient Advocate Foundation
6. Consumers Advancing Patient Safety (CAPS) National Coordinating Council for Medication Error
www.patientsafety.org Reporting and Prevention
http://www.nccmerp.org/consumerInfo.htm
http://www.nccmerp.org/consumerInfo.htm
l

29. INTERNET RESOURCES FOR DRUG INTERACTIONS
http://medicine.iupui.edu/clinpharm/DDIs/clinicalTable.asp Chart
www.arizonacert.org Drug interactions
www.drug-interactions.com P450 mediated drug interactions
www.torsades.org Drug induced arythymias
www.penncert.org Antibiotics
www.deri.duke.edu/research/fields/certs.html Cardiovascular Meds
www.ascpt.org Clinical Pharmacology
www.epocrates.com Smart Phone accessible data base

30. Internet Sources for Pharmaceutical Information:
www.drugs.com
www.nlm.nih.gov/medlineplus/druginformation
www.rxlist.com
www.webmd.com/drugs
www.fda.gov/Drugs
www.medicinenet.com/medications
www.rxlist.com/pill-identification-tool/article.htm
www.drugwatch.com

31. Physician / Hospital Records to Obtain:
MD Office chart Hospital Records, EMR (electronic) :
Pt intake questionnaire Pt registration form
Current Medication List Admitting History & Physical
List of allergies, drug reactions MD Orders
Medication refill sheet, orders MD Progress notes
Medication administration records Consultation Reports
Pharmacy refill requests Operative Notes
Out patient visit MD, NP, RN notes Intra-operative nursing notes
Intra-
List of Medication samples given PT Anesthesia Record
Previous MD office charts PACU Records
Telephone, email communications with Medication Administration Reports
patient or family Nursing Graphic
All EMR (Electronic Medical Records) Laboratory Reports
Hospital pharmacy records
Discharge Notes
Discharge Instructions
All Billlings for medications, devices, etc.
All EMR records

32. Pharmacy Records to Obtain:
Physician / MD Prescriptions (RX’s)
(RX’ Patient Communications / warnings
Handwritten / hard copy
Fax’d prescription orders
Fax’
Log of Telephone calls, communications
Email, EMR prescriptions with patient, family member, or SNF staff
All medication refill orders Copy of all Instruction / drug detail sheets
Telephone log of communications with given to patient with any medication
prescribing MD re any med Rx
Medications Provided
All Docs re Patient Medication Reaction(s)
Reaction(s)
All hard copy records Notes re Pt reports of reaction
All computer / EMR records EMR / Computer records
Records of all drug warnings, instructions, SNF records / reports of Med Reactions
Pharmacist advice / warnings to Pt
All billings to Pt , Medicare or Health Insurance
company for medications Billing Records to:
Directly to Patient
Drug Interaction Searches Medicare / Medicaid
All records of any searches for possible
drug interaction with other Pt meds
Private Health Plan
Records of Notice to Rx’ing MD or Pt of any possible
Rx’ Other 3pr party payer (family)
drug interactions