Summary
This matter involved a 63-year-old male patient who had been a client of the insured pharmacy for more than five years. After 30 years of cigarette smoking, the patient quit but developed chronic obstructive pulmonary disease (COPD). His medical history also included hypertension and atrial fibrillation. Pertinent to this case, the patient suffered a non-fatal pulmonary embolism before beginning anticoagulant therapy—Eliquis (apixaban)—approximately seven years before this medication error incident.
The pharmacy notified the patient that a new prescription for his anticoagulant was received and filled. The patient picked up his medication the following day. Over a two-week period, the patient experienced worsening shortness of breath (SOB) and chest pain. He later stated that he suffered a minor cut while preparing food in his kitchen. He felt it was odd that the bleeding stopped very quickly after washing the cut and applying a bandage. Finally, with pain and SOB continuing to increase, the patient presented to the local hospital emergency department (ED) for evaluation.
After examination, the hospitalist ordered a chest X-ray, electrocardiogram, and pertinent laboratory tests. A chest CT (Computed Tomography) scan followed. Imaging indicated acute pulmonary emboli involving the lower lobes of the lungs bilaterally. Narrowing of the right main pulmonary artery and middle arterial branches was also noted. Finally, a thick-walled cavitary lesion in the left middle lobe was present. According to the hospital records, this incidental finding might have been due to malignancy or an infectious/inflammatory process.
The patient brought his medications to the ED, and during the patient interview, the hospitalist discovered an issue. He consulted the patient’s pharmacy and then discussed an apparent medication error with the patient. Although the patient reported taking Eliquis for many years, the anticoagulant medication was not among those he brought to the ED. Furthermore, one of the medications was verapamil 80mg, and, according to the insured pharmacy’s records, this medication was not prescribed for the patient. In fact, the label clearly stated the medication name, and the name of another patient for whom the medication was intended. Due to the medication error, the patient had not taken his anticoagulant for two weeks.
The patient was admitted to the hospital. However, he was transferred to a larger regional hospital the following day for further assessment. After treatment and constant monitoring for four days, the patient was discharged and advised to immediately schedule an appointment with his cardiologist for follow up.
Resolution
Approximately six months after the incident, the insured pharmacy received a demand letter from the patient’s attorney. The demand described the patient’s co-morbidities, including his history of blood clots, but indicated that he had been in stable health before the medication error. The letter stated that, soon after picking up his prescription for what he thought was Eliquis, the patient suffered worsening SOB and chest pain, resulting in his ED visit and hospitalization. The demand letter alleged that the patient’s injuries (pain, suffering, mental anguish, pulmonary emboli, residual lung damage/decreased function) were a direct result of the insured’s negligence. The letter demanded $400,000 to compensate the patient for medical expenses and the injuries described.
Discussions with the insured and a review of the healthcare information records supported the plaintiff’s assertions--a wrong patient error had in fact occurred. The defense team recommended seeking expeditious settlement in order to limit the loss and claim expenses. The defense team identified the patient’s own responsibility or comparative fault as a valid negotiating point.
The defense asserted that, at a minimum, a reasonable and prudent person would review the prescription label and note the incorrect medication name, directions for use, and the incorrect patient's name. The same information was also included on the pickup receipt, signed by the patient. These points, and the notable difference in the physical characteristics of the two medication tablets, would lead a reasonable person to question the prescription and prevent harm. Even so, these points would not outweigh the professional duty to prevent harm. The case would have little to no chance of a defense verdict at trial.
Through effective negotiations, the defense team was able to reduce the initial demand, and the case was settled with a final total incurred cost of $155,200. As an aside, legal discovery was limited due to the decision to settle the case quickly. Consequently, a final diagnosis for the thick-walled cavitary lesion discovered during the patient’s hospitalization is unknown.
Risk Management Comments
Although the recently published
Pharmacist Professional Liability Claim Report: 3rd Edition includes summary data and examples of claims associated with wrong patient errors, they represent the third most frequent allegation type (7.5 percent) in the dataset, behind wrong dose/strength (21.9 percent) and wrong drug (41.7 percent) allegations. In contrast, the Institute for Safe Medication Practices (ISMP) indicates in its
2023-2024 Targeted Medication Safety Best Practices for Community Pharmacy that wrong patient errors represent the most common complaint submitted to the ISMP National Consumer Medication Errors Reporting System (
ISMP MERP). Regardless of the ranking, pharmacies and pharmacists must identify and implement appropriate methods to prevent the occurrence of wrong patient errors—and all medication errors—to prevent harm and meet the standard of care.
In this case, the pharmacy’s custom and practice was to read the patient’s name and date of birth to the person picking up the prescription for confirmation. This practice was not documented in a pharmacy policy/procedure. In any case, this method does not confirm that the medication is being dispensed to the patient, or a person authorized by the patient, and it may result in a privacy violation by releasing protected information without authorization. Instead, the person picking up the prescription should provide the patient’s name, date of birth and/or other appropriate identifiers.
Risk Management Recommendations to Prevent Wrong Patient Errors
Consider the following risk management recommendations:
- Confirm patient identification. Implement and document a standard procedure to confirm patient identity by requesting at least two identifiers, such as the patient’s full name and date of birth. Other identifiers may include, but are not limited to, telephone number, address, account number or healthcare information record number.
- Confirming identity applies to more than dispensing. Use at least two identifiers when receiving a prescription to be filled, when delivering prescriptions, before administering vaccines or other medications, and for telephone communications with patients, guardians or other professionals regarding a patient and their medications.
- Compare identifiers to the prescription, prescription label, the pharmacy information system or other appropriate source to confirm identity.
- Use technological enhancements at the point of sale that require pharmacy staff to verify the patient’s identity before the register transaction can be completed.
- When completing the dispensing process, review the prescription label and associated information with the patient to confirm that all details are correct.
- Supervisors and managers should periodically observe and confirm the consistent application of the patient identification process. Encourage suggestions to improve the process and adherence.
Wrong patient medication errors may cause serious harm and fatalities because of unanticipated drug interactions, allergic reactions, failure to receive necessary medication, unforeseen contraindications, and more. Mitigation and prevention of these errors is essential, but only one component of an effective medication error plan.
For additional information, refer to the many resources included in the CNA/HPSO
Pharmacist Professional Liability Claim Report: 3rd Edition and those available from sources such as:
Disclaimer
The information, examples and suggestions presented in this material have been developed from sources believed to be reliable, but they should not be construed as legal or other professional advice. CNA accepts no responsibility for the accuracy or completeness of this material and recommends the consultation with competent legal counsel and/or other professional advisors before applying this material in any particular factual situations. This material is for illustrative purposes and is not intended to constitute a contract. Please remember that only the relevant insurance policy can provide the actual terms, coverages, amounts, conditions and exclusions for an insured. All products and services may not be available in all states and may be subject to change without notice. “CNA" is a registered trademark of CNA Financial Corporation. Certain CNA Financial Corporation subsidiaries use the "CNA" trademark in connection with insurance underwriting and claims activities. Copyright © 2024 CNA. All rights reserved. Any references to non-CNA websites are provided solely for convenience and CNA disclaims any responsibility with respect thereto. Published 10/2024.