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Commentary

Pharmacist Admits to Filling Error After Patient Death

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November 21, 2019

latnerMedication errors are not uncommon, and they result in numerous deaths per year. However, pharmacists are rarely directly sued. Usually, other medical professionals such as physicians, or the pharmacy itself is sued. This month we look at a case where the pharmacist was sued, after admitting to the error which was alleged to have caused the patient’s death.

Just the Facts

The patient, Mrs. H, was a 67-year old woman with multiple health issues (including a history of cancer) who was on several medications, including pain medication and antidepressants. For the past 18 months, Mrs. H had been taking 5 mg of methadone. But when she came to the pharmacy for a refill, the pharmacy tech typed it incorrectly into the computer as 10 mg. When the pharmacist filled the prescription, he failed to note the discrepancy in dosage between the prescription presented and the electronic file. Mrs. H was given 10 mg tablets instead of her usual 5 mg tablets.

Four days later Mrs. H died. The coroner ruled that her death was due to multiple medical intoxication.

When the pharmacy heard about the patient’s death, they reviewed Mrs. H’s files’ and realized that the patient had been given the wrong dosage.

When the pharmacist (who also was the owner of the small pharmacy) realized that he had mis-filled the prescription, he was filled with remorse. He immediately wrote a letter to the prescribing physician:

“We are contacting you to let you know of an error that took place in our dispensing of medication to Mrs. H,” read the letter.

It went on to note that “the prescription was written as it usually was and the dispensing of 10 mg was an error of the pharmacy.”

A few weeks later the patient’s widower, Mr. H, went to see her physician.

“I want to know why my wife died,” he said to the doctor. “I’m thinking of going to court if I have to in order to find out.”

“I’m very sorry about your loss,” said the physician, “but I’m not worried about a lawsuit since I got the letter from the pharmacy.” He showed Mr. H the letter admitting to the error on the part of the pharmacist.

The widower did not sue the physician, but he did sue the pharmacist.

The Case

The plaintiff (the widower) claimed that the pharmacist’s error, which the pharmacist admitted to, was the cause of his Mrs. H’s death. The defense attorney for the pharmacist claimed that that although there was an error, there was no clear line between the error and Mrs. H’s death, since she was on numerous medications.

The pharmacist decided to settle the case prior to trial, and it was settled for $325,000, just under the malpractice damages cap allowed in the state. The pharmacist was also subject to a Pharmacy Examining Board action and ordered to complete eight hours of education about controlled substances and to pay a $500 fine to cover the cost of the state proceedings.

The Takeaway

While it was admirable of the pharmacist in this case to recognize his own error and own up to it, it could have been handled in a better manner. Before writing such a letter, the pharmacist should have consulted with his malpractice insurance company or his attorney to get advice on how best to present the information.

In this case, the attorney for the plaintiff noted that the letter strengthened her case. “A strong inference could be made from the letter that her death was a result of the mistake,” she said.

“Mr. H did suffer a loss, an error was made,” said the attorney for the pharmacist, who then went on to note that “there is a debate about whether there is a causal connection between the two.” But he also noted that the pharmacist was “very honorable in owning up to the mistake.”

While owning up to errors is applaudable and appropriate, always seek counsel before sending such a letter to a patient or a physician. 

Ann W. Latner, JD, is a freelance writer and attorney based in New York. She was formerly Director of Periodicals at the American Pharmacists Association.

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