Did you know that medication errors are among the most common and avoidable causes of patient harm? These mistakes can occur at any stage, from prescribing and labeling, to administering a drug. In fact, medication errors are responsible for more deaths each year than workplace injuries. According to the Institute for Healthcare Improvement, 21% of U.S. adults report having personally experienced one. And there’s a long list of personal injury and medical malpractice cases that back this up.
Wyeth v. Levine: A New Era for Drug Manufacturers
Take the landmark case, Wyeth v. Levine, which reshaped the balance of power between federal drug regulations and state consumer protections. After patient Diana Levine lost her arm to gangrene caused by an injection of the anti-nausea drug Phenergan, she sued pharmaceutical giant Wyeth. Although the drug’s FDA-approved label mentioned potential risks, it didn’t explicitly prohibit the IV-push method used in Levine’s treatment. When the drug accidentally entered an artery (a major risk of the IV-push method), it caused irreversible tissue damage, which ultimately led to the amputation.
Levine sued Wyeth for failing to adequately warn against that method of administration, resulting in a multi-million dollar verdict.
Wyeth argued that FDA approval of the label shielded it from state liability. But the Supreme Court disagreed, ruling that drug manufacturers, not the FDA, are ultimately responsible for ensuring labels reflect all known risks. The decision reinforced states’ rights to hold drug companies accountable and highlighted the importance of tort law in protecting public health when federal regulation falls short.
Why Medication Errors Are So Common & How to Prevent Them
Medication errors are a growing problem in the United States. According to the Pennsylvania Patient Safety Reporting System (PA-PSRS), medication errors had the largest increase in their share of total incidents compared to other patient safety event reports, rising from 13.2% in 2022 to 14.1% in 2023.
Contributing to these numbers is the common practice of transferring medications into unlabeled containers. Just like in the Levine case, improper labeling or failure to fully communicate risk can result in severe injury or death.
To prevent these outcomes, every medication must be labeled properly in perioperative and procedural settings, both on and off the sterile field.
Labels should include:
- Name of the medication or solution
- Strength
- Amount (if not obvious from the container)
- Diluent name and volume (if applicable)
- Expiration date and time (may be omitted for short procedures)
Verification must be both verbal and visual. If the person preparing the medication is not the one administering it, two qualified individuals must verify the label. Labeling must be done immediately upon transferring a medication into a new container, unless it’s administered immediately, without interruption.
Mislabeling isn’t the only risk. Confusion with IV tubing and administration routes can also cause harm. To reduce these risks, hospitals and clinics can use strategies like color-coded lines, standard concentrations of high-risk medications, smudge-proof labeling materials, and immediate labeling of all syringes.
Best Practices for Medical Professionals Who Administer Medications
But as we saw in Wyeth v. Levine, even a correctly labeled drug can be dangerous if providers don’t account for context. Proper labeling is only one piece of the puzzle. Providers must also consider each patient’s full clinical picture. Below, we’ll look at several best practices, and potential consequences if they’re not followed.
Best practices include:
Ensure prescription accuracy.
In 2021, a Washington pharmacy gave a patient the wrong medication, causing the patient to collapse. A simple verification could have prevented the incident.
Double-check for look-alike/sound-alike drugs.
In New Jersey that same year, a child experienced severe side effects after receiving Clonazepam instead of Clonidine. And in 2022, a Florida nurse mistakenly gave a newborn Ephedrine instead of Epinephrine during a resuscitation. The error caused severe brain damage. These kinds of mistakes can be avoided with an extra moment of attention, especially in high-pressure situations.
Know your patient’s medical history.
A 27-year-old in substance abuse treatment died in Pennsylvania in 2020 after being given a medication that suppressed his central nervous system. A wrongful death lawsuit alleged that the hospital administered medication without first reviewing the patient’s medical history, constituting negligence.
Check for drug interactions.
That same year, an Illinois woman was prescribed an antibiotic that reacted dangerously with her blood pressure medication, leading to statin toxicity and muscle breakdown.
Conduct appropriate lab work before changing medications.
In 2019, a Texas woman died from a stroke after her doctor changed her blood thinner without proper lab testing.
Consider the patient’s current state of sedation or intoxication.
Also in 2019, a Pennsylvania hospital administered a combination of Morphine, Methadone, Oxycontin, Oxycodone, and Xanax, to a patient already intoxicated, resulting in a fatal overdose.
Verify patient identity before administration.
In Utah, a 71-year-old man died in 2015 after receiving Morphine meant for another patient. He had a fatal allergic reaction.
Each of these cases shows that administering medication requires medical professionals to think critically and consider the full picture. Every patient brings a unique set of risks and needs, and every provider holds the power to protect them through careful, informed actions.
How to Create a Compelling Case
If you’re a personal injury or medical malpractice attorney, chances are you’ll encounter a medication error case at some point in your career. But not every case involving a medication error is straightforward. A client may have been impacted, but that doesn’t always mean the injury was significant, or that the case will hold up under scrutiny. Building a strong, defensible argument starts with identifying potential red flags early.
At Integrity Legal Nurse Consulting PDX, we specialize in helping attorneys navigate these complexities. We’ll review your client’s medical records with precision, flag any issues that may weaken your case, and create a clear, compelling timeline of events that resonates with both judge and jury.
We bring particular expertise in medication error cases, especially those that occur in healthcare facilities. Our network of thoroughly vetted, specialized nurses is available to provide expert testimony in support of your case. Our services also include detailed cost projections for future care needs, and an assessment of the reasonableness of charges based on current industry standards and geographic norms. Medication error cases are often shaped by details that are easy to overlook.
Let us help you uncover the critical elements that strengthen your argument. Schedule a free consultation to get paired with an expert legal nurse today.
Sources:
- Medication Dispensing Errors and Prevention | National Library of Medicine
- Errors in Health Care: A Leading Cause of Death and Injury | National Library of Medicine
- Americans’ Experiences with Medical Errors and Views on Patient Safety | Institute for Healthcare Improvement
- Wyeth v Levine: Implications for Public Health Policy and Practice | National Library of Medicine
- Patient Safety Trends in 2023: An Analysis of 287,997 Serious Events and Incidents From the Nation’s Largest Event Reporting Database | Patient Safety
- Medication Error Settlement Amounts and Jury Payouts | Miller & Zois, LLC
- National Patient Safety Goals® Effective January 2025 for the Hospital Program | The Joint Commission
- Root Cause Analysis and Medical Error Prevention | National Library of Medicine
- Human errors and their prevention in healthcare | National Library of Medicine