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    Pharmacy dispensing errors: Claims study emphasizes need for systematic vigilance

    Quality improvement systems and multiple levels of check-offs are critically important to help pharmacies catch errors before they reach patients, according to a 10-year study of closed claims and several pharmacy industry experts.

    A collaboration between the pharmacy underwriter group CNA and Healthcare Providers Service Organization, the study, titled “2013 Pharmacist Liability: A Ten-Year Analysis,” examined data from CNA’S closed claims, finding that 75.3% arose from patients receiving either the wrong drug (43.8%) or the wrong dose (31.5%). 

    In resulting injuries reported in the closed claims filed between Jan. 1, 2002, and Dec. 31, 2011, overdose occurred 13.6% of the time and death, 11.7%.

    See also: Are VA workloads, lack of standards causing pharmacy errors?

    Pharmacist risk exposure

    Jennifer Flynn, HPSO’s manager, healthcare risk management, said the analysis was prepared to educate pharmacists on their risk exposures and to increase patient safety. HPSO insures more than 70,000 pharmacists nationwide.

    See also: Professional liability insurance: A short primer

    “We wanted pharmacists to be aware of the top allegations made against them in malpractice lawsuits, so that they could incorporate strategies into their daily custom and practice to help manage their own risks,” she said in an e-mail to Drug Topics.

    Errors involving prescriptions for minors resulted in an average paid indemnity of more than $196,000, although only 15.4% of the claims studied involved children. The highest percentage of claims involved adults ages 18 to 64, with an average paid indemnity of $52,031. Claims involving mistakes in prescriptions for seniors, 29.6% of those in the study, resulted in an average paid indemnity of $78,321.

    The analysis also showed that independent or individually owned pharmacies or pharmacy franchises accounted for 46.3% of the 162 claims studied, while national or regional chain pharmacies accounted for 34.6%. The next-highest number of claims involved hospital inpatient pharmacy with 4.3%.

    However, Flynn noted, the report should not suggest that certain types of pharmacies are more likely to experience a claim. The conclusion is “just a function of the mix of pharmacy types we see in our program,” she said.

    Severe patient harm

    An equal percentage of mistakes (11.7%) cited in the study resulted in permanent patient harm and death.

    See also: Patient harm and pharmacist liability

    Of mistakes resulting in permanent harm, three claims were resolved at policy limits:

    • A child suffered permanent brain damage because of infusion of improperly compounded total parenteral nutrition.

    • An adult suffered permanent brain damage following simultaneous overdoses of promethazine and fentanyl.

    • An infant was born prematurely and with permanent brain damage when a Prostin suppository was dispensed instead of the progesterone suppository that was ordered.

    Two children died, one from a clonidine compounding error and the other when propylthiouracil was dispensed instead of 6-mercaptopurine, which resulted in the child receiving no chemotherapy for leukemia. An adult patient wrongly received intrathecal morphine and died.

    Some 9.3% of claims required an intervention to sustain the patients’ lives following dispensing errors. In one case, a wrong dose of tacrolimus led to the failure of a patient’s transplanted liver, requiring the patient to undergo a second transplant.

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