Missouri Personal Injury Attorney Blog

The FDA recently announced plans for a pilot project to help pharmaceutical companies select safer drug names. By “safer,” they mean names that are less likely to cause medication errors, which are the most common type of medical mistakes that are made.

Within the category of medication errors, mistakes most often involve a drug with a similar name to the medication a doctor actually prescribed. The Associated Press reported in September that drug name mix-ups account for about 25 percent of the 1.5 million Americans estimated to be harmed each year from medication errors.

Some estimates put the number of deaths due to pharmacy errors at 7,000 each year. Another startling statistic is that about 5 percent of all prescriptions filled annually in the United States are incorrect.

In my firm’s experience representing victims of medication errors, about 60 percent of our cases involve drugs with those that have a name similar to the prescribed medication. Take Lamictal and Lamisil, for example. They sound similar but are very different drugs: Lamictal is a medication sometimes prescribed for patients with epilepsy or bipolar disorder. Lamisil is used to treat fungal infections in fingernails or toenails. Serzone and Seroquel also sound kind of alike, but Serzone is for depression, and Seroquel is for schizophrenia.

I’ve also read that the Alzheimer’s drug name Reminyl changed to Razadyne after two deaths occurred over mistakes with a similar-sounding drug called Amaryl, a medication used to treat diabetes. Many drugs that are spelled similarly are stocked on pharmacy shelves right next to each other, since they organize medications alphabetically.

In the age of big-box pharmacies operating under corporate pressure, financial constraints and over-burdened or under-qualified staff, it’s no wonder that mistakes occur.

Although the FDA’s pilot program is a step in the right direction, the problem of drugs with similar names is going to continue to create confusion and error in our nation’s pharmacies.

When it comes to medication errors, some populations are more vulnerable than others. Take the elderly, for example. A U.S. Pharmacopeia study confirms that older people are more commonly affected by medication errors than other age groups.

This is true for a few reasons. Because the elderly are more likely to be taking multiple medications – sometimes prescribed by multiple doctors – they are more susceptible to harmful drug interactions. Elderly people are also more trusting, and so they are less likely to question health care providers or the medications they are taking. Also, physical ailments such as decreased mental capacity or vision difficulties make it more difficult for an elderly person to catch a mistake.

Ironically, some studies show that elderly patients may be at greater risk of falling victim to medication errors when they are confined in a hospital or nursing home. Many factors come into play that increase the risk of a medication error within a health-care facility, including over-burdened nurses, pharmacists, and doctors.

In a hospital setting, medication errors can happen at any step of the “delivery” process, the path a medication follows from the moment a physician writes a prescription to the time it is administered to a patient. Hospital medication errors are fairly equally distributed along the delivery process:

• Physician error – A doctor writes the wrong prescription;


• Hospital pharmacy error – Pharmacists or supporting staff either transcribe the prescription or they prepare the drug incorrectly;


• Bedside administration error – Nurses make a mistake administering the medicine.

Most medication errors in nursing homes occur due to medication timing issues. A medication is either given too often, not frequently enough or not at all. Timing is often a critical issue for the elderly, who may depend on the right drug, in the right dose, at the right time to sustain their life.

Another big concern at nursing homes that drives up the rate of medication error is staff issues. It is a fact that many nursing homes are not only downsizing staff due to financial constraints, but are also depending more and more on the remaining employees to take on additional responsibilities. That results in an over-burdened staff who, in many cases, is under-qualified to do some of the extra work, such as administer meds to elderly patients. Adding to the problem is a nationwide shortage of qualified nurses.

It would be short-sighted to simply blame the increasing medication error risk on individual carelessness of pharmacists, nurses, and other health-care workers. In fact, the root cause of medication errors among the elderly is a systemic problem that cuts to health-care managers. As long as profit rides above patient safety, medication errors will only increase.

In my medication error practice we have represented a number of children who have fallen victim to a medication error. These cases tend to be complex because small and sick children are usually less able to tolerate a wrong medication or an unintended overdose.

Our past legal case experience confirms the general evidence that children are more prone to medication error because most medications are formulated and prepared for adult usage. When a child is prescribed an "adult medication", the pharmacist must significant alter the dosage using a series of pediatric parameters. Obviously, when special preparation is required for a medication, the risk of medication error substantially increases.

While dosage mistakes represent a large portion of medication errors involving children, we have had several cases where the administration instructions on the label or insert information is incorrect. Again, most administration instructions are geared for adult use and therefore this is a fertile place for error.

Most pediatric medication errors are caused by performance neglect and carelessness in the preparation and delivery process. For example, pharmacy computer software safety alerts warning the pharmacist to take into account the age, weight, and medical history were either by-passed or ignored. Unfortunately, safety alert neglect is not uncommon in a busy retail pharmacy where a high number of prescriptions are being prepared in rapid order.

There is another note that deserves mention. Because child weight is a key factor in proper medication dosing, the child's present weight, in kilograms (kg) should be reflected on the pharmacy or medical records. Kilogram weight of the patient is required because the proper standard for prescription medication preparation is based on the metric system. However, if the weight of the child is reflected in pounds (lbs.), the possibility of medication error is increased because the patient's profile reflects a wrong weight.

Medication errors occur with children because full pharmacy and medical oversight is lacking. Safe dispensing of pediatric medications requires that every step of the medication delivery process is accounting for the special requirements of a child. When an error does occur, and the resulting case is properly handled, the valuable by-product is that the offending pharmacy or health-care facility will be far less likely to make a future pediatric error.

Medication errors are one of the nation's leading cause of death, killing more people each year than motor vehicle accidents, breast cancer, or AIDS. Further, experts agree that the majority of medication errors are preventable.

My experience with legal cases and claims confirms this. Over the years I have represented people across the nation who have been injured by a pharmacy mis-fill. My clients range from infants to the elderly and the majority of our pharmacy cases involve preventable error.

In almost every instance, errors in the pharmacy involve some sort of human error. For example, the pharmacist or pharmacy tech fails to ensure that the right customer receives the right medication in the right dosage with the right label and/or administration instructions. Other contributing factors include:

• Environmental Distractions - increasing customer demands, work interruptions such as ringing telephones, high noise levels, and other distractions common to a busy pharmacy.


• Staffing Issues - this usually concerns too few pharmacists and pharmacy techs, some of whom may not have the necessary experience or training.


• Procedure Breakdowns - polices, procedures and protocols designed to enhance safety are not always followed.

Add to this the profit objectives of the large retail pharmacy, and pharmacy errors represent a growing problem with potentially fatal consequences.

While pharmacy errors may be a reality of our present day, customers of pharmacys can keep themselves safe by making sure they carefully inspect their medication before leaving the pharmacy.

Moreover, if a re-filled medication looks different in color, shape, size, or appearance, talk to your pharmacist before you take the medication. I have had at least 20 cases where my client assumed that the different looking medication was from a different manufacturer or was a so-called generic drug.