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



















