WHEREAS, The error occurred because a pharmacy technician at
Mercy Fitzgerald Hospital wrongly labeled the intravenous bag
containing the medicine; and
WHEREAS, A report on the medication error incident later
found that the pharmacy technician was in fact not a technician,
but rather a certified intern and should have been supervised;
and
WHEREAS, Under current State law, pharmacists are not
required to notify the Pennsylvania Board of Pharmacy about
medication errors, but instead must notify the prescribing
doctor of a medication error within 24 hours of the error; and
WHEREAS, Since pharmacists are not required to notify a State
agency, many times this leads the hospital to only conduct an
internal investigation of the error rather than involving the
Department of Health; and
WHEREAS, Hospitals are required to report "serious events,"
which are instances that result in death or serious harm to a
patient, and "incidents," which are events that could have
resulted in the death or serious harm to a patient, to the
Pennsylvania Patient Safety Reporting System (PA-PSRS); and
WHEREAS, According to the Pennsylvania Patient Safety
Authority's 2022 Annual Report, there were 257,000 reports made,
which included 247,000 reports regarding "incidents" and 10,000
reports regarding "serious events"; and
WHEREAS, The United States Food and Drug Administration (FDA)
has worked to reduce medication errors by reviewing medication
names, packaging, labeling and directions for all medications
and required barcodes to appear on some medications for the
purpose of ensuring the correct strength and type of medication;
and
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