Escalating medication errors pose grave risks for Pennsylvania patients

A Pittsburgh-area woman died after having an allergic reaction to an antibiotic she was given not once, but twice, during surgery to repair a hernia.

During the first surgery, the procedure was halted because of the allergic reaction.

The second time, the surgeon insisted she get the antibiotic because he thought the woman's reaction was initially misinterpreted, Pittsburgh attorney Jon Perry said.

"It's inexcusable conduct," he said, calling it one of the most egregious cases of medication error Perry has handled during his nearly 35 years as a medical malpractice attorney.

The antibiotic was administered to the woman to prevent infection during the surgery. But, Perry said, "There were hundreds of other antibiotics they could have used."

Medication errors are the most common cause of patient injury, resulting in an estimated global annual cost of $42 billion, according to the World Health Organization . The Food and Drug Administration each year receives more than 100,000 reports of such errors, affecting about 7 million U.S. patients.

In Pennsylvania, medication errors are in the spotlight following the case of a Sewickley Township woman who says in a lawsuit that she was given the wrong medication during back surgery at Forbes Hospital.

With its own reporting system, Pennsylvania has documented annual medication errors ranging between 33,980 and 52,884 over the last five years. Last year's total was 40,680.

Statistics show an increase in serious errors that have harmed or killed patients, although the total number of reported errors in the state has gone down in recent years.

Most cases of medication error come down to people making mistakes and patients are at the mercy of their care team when they're in a hospital, Perry said.

"You don't have access to the information you would get with your medication when you have your prescription filled at the pharmacy," he said. "A lot of drugs are administered by IV."

Ben Cohen, an attorney with a different Pittsburgh malpractice firm, agrees that human failure typically is involved in a medication error.

Understaffing and the added pressure it results in can contribute to errors, Cohen said.

"It's a big issue with a lot of these facilities," he said. "Maybe a staff member isn't able to fully review a patient's chart and that would lead to the inability to properly administer the medication."

Medication errors that caused serious harm or death to patients have increased from 166 in 2020 to 294 in 2023, according to data from the Pennsylvania Patient Safety Reporting System.

Medication errors can include something as simple as a missed or extra dose, but the most prevalent by far was use of the wrong medication. There were just over 13,000 incidents where the wrong medicine was given in 2022. It was just over 15,000 in 2023.

Audrey Lindsey of Sewickley Township suffered vocal chord, brain damage and other ill effects after being given the narcotic methadone instead of the muscle relaxant methocarbamol during her Jan. 13 surgery at Forbes. She's suing the hospital, Allegheny Health Network, and the anesthesiologist and nurse anesthetist who were part of her care team.

The hospital admitted to the mistake, but it's unclear how it happened, according to the lawsuit.

What happened to Lindsey is characterized in the medical community as a "never event," according to the lawsuit.

"Never events" are clearly identifiable, preventable, and serious in their consequences for patients, according to the National Quality Forum.

Dan Laurent, vice president for corporate communications at Allegheny Health Network, said, "The event in question was recognized immediately by the medical team, thoroughly investigated for process improvement moving forward, and reported in full transparency to both the patient's family and the (Department of Health) as required."

UPMC, the region's largest hospital network, said it has safeguards in place to avoid medication errors, such as inadvertent removal of similarly named medications.

Neither health care system responded to TribLive's request to speak to medical staff to learn more about its medication procedures.

Independence Health System, which operates hospitals in Westmoreland, Butler and Clarion counties, also declined to comment when asked about its process for handling medications.

Dr. Elizabeth Rebello, a professor of anesthesiology and perioperative medicine at the University of Texas MD Anderson Cancer Center, advocates for having more medications available in pre-filled syringes to administer to patients. She said that's one way to mitigate against such potential errors as providing a patient the wrong drug or an incorrect concentration of a drug.

With a pre-filled syringe at the ready, medication doesn't have to be drawn from a vial — a step that introduces another opportunity for error, especially if different drugs are supplied in lookalike vials that are similarly colored or sized.

Label challenge

Operating rooms at facilities in California's UC Davis Health system have access to a limited supply of pre-filled syringes, according to Dr. Rob Aldwinckle, an anesthesiologist and professor of clinical anesthesia at the UC Davis Medical Center.

Aldwinckle, who has co-authored a case study of drug errors in the operating room, said pre-filled drugs most readily available at the medical center are phenylephrine, commonly used to relieve symptoms of nasal and sinus congestion, and succinylcholine, a muscle relaxant.

But, he said, since the majority of medications used at the center must be drawn from vials, visually checking labels is part of the process there.

Eyeballing the label should help detect if a vial of medication was placed in the wrong storage compartment. Aldwinckle noted controlled drugs at UC Davis are kept in locked compartments that are accessed using a password or a fingerprint.

Use of bar codes to identify and label medications is another safety measure cited by advocates, but one that health care experts say isn't widespread.

"We have a bar code reader which helps a lot," said Aldwinckle. "You can scan the medication and the machine.... prints a label appropriately dated/timed/signed with color code and correct concentration. I suspect it is not industry standard and a lot of hospitals probably rely on the provider labeling the medication actions."

Guidelines for medication management and handling at hospitals can vary by the facility and by the regulatory agencies at various levels that are involved in oversight.

The Joint Commission, the accrediting organization for most U.S. hospitals, has medication management standards that apply in all hospital locations were medication is administered — including in surgery.

According to Robert Campbell, a senior director with the Joint Commission, medication containers are to be labeled in a standard format whenever medications are prepared but not immediately administered. The labeling occurs when any medication or solution is transferred from the original packaging to another container.

Information that must be displayed on the label includes the name and strength of the medication, the expiration date and time.

If the person preparing the medication is not the person who will be administering it, the medication labels must be verified both verbally and visually by two qualified people.

"We're only human, but if the right system is in place, there are checks and balances," said Cohen. "Having the right staff in place and the right amount of staff with the right training should hinder the ability of one simple human error to have such a great effect."