Medication errors occur in a pharmacy under the best of conditions. However, a previous Missouri court ruling regarding a pharmacy medication dispensing error clearly shows that a lack of proper supervision, documentation and up-to-date policies and procedures will not be tolerated when the public’s safety is placed in jeopardy as a result. In an excellent article just released in the Australian Journal of Pharmacy, an extremely valid point is made: the owner of the pharmacy is always ultimately responsible! The point was well made that although many pharmacies are owned by pharmacists (or non-pharmacists) who do not actually work in them, in the end it is the owner’s responsibility to make certain that current and up to date Policies and Procedures are maintained and followed by all of the pharmacy’s staff. Being an “absentee” owner will not stop the legal ramifications of dispensing errors and other mistakes by employees that could (and should) have been prevented.
The Missouri Case and Ruling
The Missouri Court of Appeals (Western District) reversed a lower court’s decision in late October that centered around a medication dispensing error by a pharmacist in Missouri. The dispensing error occurred when a pharmacy technician took several prescriptions over the phone from a Registered Nurse on behalf of the physician who was discharging his patient from the hospital. Although several mistakes were actually made by the technician, the most significant medication dispensing error was that the prescription phoned in by the RN for the patient’s metolazone was transcribed incorrectly to read methotrexate. The directions given to the patient for “once daily” administration of the drug inherently led to the patient’s death less than three weeks later (after she followed the directions on the Rx bottle and took a dose each day).
The family sued after the patient’s death and was awarded $2,000,000 in damages by a jury after a trial. Even though gross negligence was proven and admitted by the defendants in the initial trial, the damages awarded were reduced by a lower Missouri appeals court to $125,000 (based on Missouri statutory caps and limits to damages awarded by a jury). The victim’s family further pursued the ruling, which eventually led to the recent reversal by the higher court. The court upheld the jurors’ decision to award the patient’s family the additional damages that they initially awarded for pain and suffering caused by “aggravating factors and circumstances” resulting from the medication dispensing error by the pharmacy.
The Four (4) Medication Dispensing Errors as Noted By The Missouri Court
What makes this case so noteworthy is that the Missouri Court of Appeals actually broke down the case into four separate incidences of medication errors occurring in the pharmacy’s process of dispensing the prescription.
1. The first error cited by the court was that the technician took the prescription verbally over the telephone. Although currently Missouri is one of the seventeen (17) sates that allows pharmacy technicians to take prescriptions verbally by telephone, the court noted that the pharmacy’s own policies and procedures actually prohibited this practice and state that only RPh’s are allowed to accept prescriptions via verbal phone communication.
2. The second error was that the pharmacist did not question the methotrexate being administered once daily. In conjunction was the fact that the pharmacy’s computer system failed to “flag” the daily methotrexate dose. The court’s opinion stated that the pharmacist failed to properly review the medication and its administration, plus the court noted that there was a lack of a computerized “hard stop” for methotrexate prescriptions prescribed to be administered once a day.
3. The third error cited by the court was the failure by the pharmacy to provide the patient with the necessary education and the required patient counseling when dispensing a new Rx to a patient. Especially when the prescription is for a high risk medication (such as methotrexate is).
4. The fourth and perhaps most significant error cited by the court was the fact that the pharmacy “had made no meaningful changes to its procedures as a result of the patient’s death.” The court noted that in the twenty (20) months since the original verdict in February of 2016, the pharmacy had failed to update and document any changes to their policy and procedures manual. This included any documented updates to their procedures regarding a pharmacy technician’s role in the prescription dispensing process.
Minimizing Medication Errors and Pharmacy Dispensing Errors
The FDA defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or harm to a patient”. A study released back in 2006 by The Institute of Medicine (a part of the US National Academy of Sciences) showed that medication errors result in harm to at least 1.5 million patients annually. Another study showed that over 400,000 patient injuries take place in hospitals in the US alone due to medication errors. Medication errors occur for a variety of reasons. and everyone agrees that no one is perfect. Yet in today’s society of consumers having more access to drug information than ever before, medication dispensing errors by pharmacists are being reported much more frequently. As a pharmacy owner and/or practitioner, we all need to take a hard look at this and ensure that best practices are always being followed to the best of our abilities. As the National Institute of Health (NIH) points out: “Errors will always occur in any system, but it is essential to identify their causes and attempt to minimize the risks”.
As a pharmacy owner or manager, ask yourself the following questions:
– Do you ensure that if a mistake is made that you have documentation that will prove that you made changes to your written Policy and Procedures to show that you take every step possible to avoid medication dispensing errors?
– Is your staff properly trained and able to document situations where a mistake is made? Do you have job descriptions for your technicians and support personnel?
– When was the last time that your pharmacy took a good look at how it dispenses prescriptions and medications, plus how you document patient counseling?
– Are you following “best practices” and limiting the chance for potential medication dispensing errors (and therefore reducing your risks of potential lawsuits and bad publicity)?
If your answers are “not lately”, then we strongly advise that you get a qualified pharmacy consultant to take an objective look at your policies and procedures. An objective third party review may mean the difference between a court ruling like the damaging case seen in Missouri and your pharmacy maintaining its good reputation.
Pharmacy consulting is an area that most pharmacy owners don’t take advantage of until it is too late. At HCC we stress that addressing and preventing issues before they occur is the key to avoiding future problems, lawsuits and bad publicity. The old cliché that “an ounce of prevention is worth a pound of cure” has never been more relevant than it is today.
About Healthcare Consultants
Healthcare Consultants has been in the business of Pharmacy Consulting for over 29 years now. Known as one of the nation’s leading full service pharmacy staffing companies, HCC is also one of the industry leaders in providing a full range of professional pharmacy consultation services to its vast array of clients. Owned and operated by pharmacists, Healthcare Consultants can provide proven expertise and experience in all facets of pharmacy operations, including retail, hospital and specialty pharmacy venues. With a full-time staff of in-house Pharmacy Consultant specialists, HCC can answer any questions that you may have in all areas of your business. Contact us online or call us today at (800) 642-1652 for a free consultation to see how we can help you.