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Pharmacy Error Leads to Series of Medical Miscues, Wrongful Infant Death and Criticism of Health Information Systems

PediatricsWhile the days of pharmacists actually producing most of the medications we take are over, some dosage forms can only be made in pharmacies. This is especially true for liquid medications, when pharmacists have to prepare IV bags or make the liquid equivalent of a drug that usually comes in pill or capsule form. Such reconstituting can be error-prone, and pharmacists who mix or compound medication incorrectly can be liable for negligence, possibly even when a pharmacy technician incorrectly types information into a field on a screen. And, thus, when medical and pharmacy errors stemming from health information technology end up causing patient injuries and death, the entire system of digital medical communications is called into question.

For example, just last week a Chicago area hospital, Advocate Lutheran General Hospital, agreed to pay $8.25 million to settle a wrongful death lawsuit brought against it by the parents of an infant boy who died after a series of medical errors initially triggered by an incorrectly compounded IV bag. The boy was born four months premature in 2010 and remained in the hospital’s care for the next six weeks. Then, suddenly, the infant boy died after coming out of a heart operation without any clear complications from the operation itself.

The hospital determined that a pharmacy technician unwittingly entered information into a computer program when processing an electronic IV order for the infant, resulting in a massive sodium chloride overdose in the bag’s solution. The infant received 60 times the amount of sodium chloride prescribed by a physician. It was also found that the automated alerts in the IV compounding machine responsible for identifying such problems were not activated at the time when the customized bag was prepared for the infant. Additionally, the hospital discovered that the outermost label on the IV bag did not accurately reflect the compound’s actual contents, and when a blood test on the infant showed an abnormally high level of sodium, a lab technician mistook the reading for an inaccuracy.

Although the series of other errors contributed to the tragedy, the initial miscue by the pharmacy technician has put a spotlight on the safety risks associated with medicine’s advance into the digital information age, a shift intended to allow doctors and medical service providers to quickly process and access patient information, previously buried in old-fashioned paper files. But the transition, as this tragic Chicago incident points out, comes with its fair share of potential problems for physicians and patients. Like any other computer or software system, hospital computers may crash or software bugs can plague a system’s information by deleting data or hiding it in the wrong place. Thus inhibiting a physician’s ability to quickly find critical patient information.

Experts also report that the alerts built into health information systems are often ignored because they occur so frequently and are often not especially useful. And, in general, many of these systems are poorly designed and difficult for doctors and nurses to use, quite possibly leading to the kind of undesired human errors we see in the case mentioned above.

It isn’t known exactly how often safety concerns arise due to health information technology, but in December the U.S. Food and Drug Administration acknowledged receiving 370 problematic reports since January 2008. These included several dozen instances of patient injuries and deaths, but the actual numbers, however, could be much higher because the filing of such reports are voluntary.

Your Charleston personal injury attorney read that the unfortunate loss to the infant’s parents, as well as the series of serious systematic shortcomings, has prompted the Chicago hospital to activate alerts for similar IV compounders used in the system’s hospitals, as well as strengthen “double check” policies for all medications leaving pharmacies.