Air Force: Medication errors at Wright-Patterson pharmacy posed 'very small' risk

By BARRIE BARBER | Dayton Daily News, Ohio | Published: May 13, 2014

DAYTON, Ohio — The Air Force concluded several prescription medication errors posed a “very small” risk to patients who had their orders refilled at the Kittyhawk satellite pharmacy, officials said Monday.

Wright-Patterson officials said in a statement they did not find instances of patients taking the wrong medications, but did find eight instances of Tylenol mixed with the muscle relaxant Robaxin.

An Air Force investigation found no harm to any patients, officials said. An automated dispensing system first cited as a possible link to the mix-up will be restarted after investigators determined it’s functioning properly and rigorous tests were conducted, a statement said.

Pharmacy employees temporarily began filling prescriptions by hand when a patient reported a mix-up April 29.

The medications were refilled at the Kittyhawk Pharmacy between April 23 to April 29, prompting warnings from base officials to contact the Wright-Patterson Medical Center to have their prescriptions verified for accuracy.

As of Monday, 926 of 1,273 patients identified as being at risk had their medicine checked via a walk-in visit or call to the Medical Center or they had not picked up their medications. Those who have not been contacted will be sent a certified letter. Seven bottles with various other prescription errors were not distributed to patients, officials said.

The Air Force Medical Operations Agency and the 88th Medical Group, which runs the base hospital, were part of the review to find out what happened and why.

It was not immediately clear what caused the mix-up based on information released Monday.

Marie Vanover, a Wright-Patterson spokeswoman, said in an email Monday the investigation’s findings were “a quality assurance document protected from release” under a federal code that shields from public release of Department of Defense medical quality assurance records.

The email added: “At this point, there are no indications that disciplinary actions are warranted,” against anyone involved in the incident. “Recommendations for appropriate modifications of processes will be taken into consideration in accordance with the investigation.”

In the original statement released Monday, officials said the investigation focused on improvements in processes and procedures to maintain and interact with a robotic or automated dispensing system.

The statement cited an “extraordinary amount” of work through the pharmacy, and the review recommended “the center build more opportunities for control structures in daily operating procedures, to include more robust mechanisms in place for communicating updated recommendations for maintaining the machine at an optimal level of performance. The review found that timely and efficient maintenance of this complex machinery is critical to its optimal level of performance and corrective action was taken to prevent future mishaps.”

A review of similar machines at other Air Force medical facilities found no problems similar to what happened at Kittyhawk, but “improved maintenance programs” will be initiated and a better mitigation and response plan was developed to improve communication between the manufacturer and the hospital, a statement said.

The Ohio State Board of Pharmacy, which tracks prescription drug errors at civilian pharmacies, does not have jurisdiction to require federal pharmacies, such as Kittyhawk, to report prescription errors, state agency spokesman Jesse L. Wimberly said Monday.

However, the agency would like to have the same rule apply to every federal pharmacy, he said.

The state board expected to inquire if a Kittyhawk pharmacist was licensed in Ohio, Wimberly said.


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