A 75-year-old female patient required multiple hospitalizations as a result of an alleged pharmacy error. The patient had a significant past medical history that included treatment for atrial fibrillation, coronary heart disease, congestive heart failure, hypertension, stage 2 chronic kidney disease and hyperlipidemia. The patient also managed borderline type 2 diabetes with dietary controls.
After a brief hospitalization to treat and stabilize the patient’s congestive heart failure, a family member sought to have the patient’s medications refilled at her local pharmacy. Approximately a week later, family members contacted emergency medical services (EMS) due to the patient suffering an apparent seizure. EMS stabilized and transported the patient to the hospital emergency department (ED). The patient was lethargic and disoriented, and tests soon revealed a blood glucose level (BGL) of 45 mg/dL. After treating the patient for hypoglycemia and an appropriate observation period, the patient was discharged with glucose tablets and home care instructions for the family to assist with nutrition and monitor the patient’s intake.
Approximately a week later, the patient returned to the ED after she experienced severe weakness and disorientation. A family member was able to assist the patient in lowering herself to the floor, avoiding a fall and injury. When EMS arrived and evaluated the patient, her blood glucose level (BGL) measured 25 mg/dL. EMS personnel administered glucagon and transported the patient to the ED. After initial assessment in the ED, she was admitted to the hospital for further evaluation. The patient was discharged after several days, without a definitive cause for the hypoglycemia having been identified. The best explanation remained poor nutritional intake.
A similar scenario occurred multiple times over the following two months, with several ED assessments and three multi-day hospital admissions. During this time, hospital personnel began to suspect that a medication error might be responsible for the patient’s recurrent hypoglycemia. Hospital personnel reviewed the patient’s prescriptions and medication containers on two separate occasions. They confirmed that no antidiabetic medications had been prescribed, and that none of the patient’s prescription containers were labeled as antidiabetics.
During the patient’s last hospital admission, a more thorough review resulted in the discovery of tablets determined to be a generic glipizide/metformin antidiabetic combination product. Hospital personnel found the tablets in a prescription container labeled as magnesium oxide. Follow up with the patient’s community pharmacy confirmed that the tablets were identical to the generic glipizide/metformin product stocked by the pharmacy. The patient and family members were informed of the error, and the patient was discharged after her BGL and health conditions were stabilized.
Resolution
Approximately six months later, the patient and family filed suit against the pharmacist, alleging professional negligence and negligent infliction of emotional distress. The policy limit ($1,000,000) demand letter asserted that the insured pharmacist/pharmacy owner failed to develop and implement adequate safety precautions, policies, and procedures to prevent the medication error. The plaintiffs further asserted that failure to enact and follow safe dispensing policies deviated from the standard of care, directly resulting in harm. Injuries and financial damages were attributed to multiple ED visits and lengthy hospital admissions due to incidents of severe hypoglycemia, lethargy, disorientation, loss of consciousness, and seizure-like episodes. These events were alleged to have caused significant emotional distress as well as de-stabilization of the patient’s overall physical health. The injuries necessitated the addition of mental health and home healthcare services to support and extend care previously provided by family members.
The pharmacy’s investigation did not reveal any significant findings that would explain the wrong medication error. The pharmacist/owner was on duty in the small community pharmacy on the date that the patient’s medications were filled. He could not recall any unusual circumstances, distractions or other factors that may have led to the error.
Without any competing explanation for access to the antidiabetic medication, such as a family member’s prescription, the defense team strongly recommended seeking settlement as soon as possible. The pharmacist agreed and provided consent to do so. The plaintiffs had not deviated from their initial policy limit demand, but agreed to mediation to see if an acceptable outcome could be reached before trial. Negotiations quickly stalled as the plaintiffs were intransigent. However, efforts were successful in a second mediation a few weeks later, leading to the $400,000 settlement agreement. While representing a significant sum, it remained less than the defense team had anticipated prior to mediation.
Risk Management Comments
The CNA/HPSO Pharmacist Professional Liability Claim Report: 3rd Edition observed that claims asserting that the wrong drug was dispensed have remained the top allegation against pharmacists. More than 40 percent of professional liability claims are attributed to this category in the two most recent claim reports.
An array of error types or contributing factors may lead to a wrong drug allegation and patient injury. Therefore, preventing medication errors must involve multiple strategies and tactics to ensure a safe dispensing process.
Risk Management Considerations
Pharmacy professionals should explore available tools and information specific to their scope of practice in order to prevent medication errors and improve patient safety. Consider the points below and seek additional recommendations in the listed resources. Readers may also access an extensive resource list in the CNA/HPSO Professional Liability Exposure Claim Report linked below.
- Use Two Patient Identifiers. Always confirm patient identity with a minimum of two identifiers, such as their full name and date of birth.
- Avoid Multitasking. Juggling multiple tasks, such as taking phone calls, managing drop-offs, while also filling medication orders, may be efficient, but may also lead to distraction and errors.
- Implement Barcode Scanning. Barcode scanning technology can help to ensure selection of the correct medication.
- Organize and Label Storage Areas. Keep medications well-organized and clearly labeled to help prevent selection of the wrong medication.
- Standardize Prescription Labels. To avoid confusion, use standardized labeling, including the use of metric units (mL) for liquid dosage forms.
- Conduct Regular Training. Provide appropriate and frequent training on safety and error prevention topics for all pharmacy team members.
- Implement Double-Checking. Whenever possible, require another pharmacist or technician to check the medication before dispensing.
- Use Technology. Along with barcodes, consider other solutions to reduce human error (i.e., e-prescribing, automated dispensing systems, etc.).
- Engage with Patients. Take time to speak with the patient, respond to questions, and ensure understanding before dispensing.
By following these and other medication safety practices, pharmacy professionals can significantly reduce the risk of dispensing errors and enhance patient safety.
Resources
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. Certain coverages may be provided by a surplus lines insurer. Surplus lines insurers do not generally participate in state guaranty funds, and insureds are therefore not protected by such funds. The claims examples are hypothetical situations based on actual matters. Settlement amounts are approximations. Certain facts and identifying characteristics were changed to protect confidentiality and privacy. “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 © 2025 CNA. All rights reserved.