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Patient harmed, 1,800 doses of controlled drugs lost at CVS pharmacy, regulator says

Pharmacy giant CVS continues to call them “isolated incidents” even after reports emerged earlier this month that the Ohio Board of Pharmacy found hundreds of problems that could endanger patients at eight of the company’s understaffed pharmacies.

Then on Thursday, the board released inspection reports from yet another CVS pharmacy that detailed additional serious problems. They include the loss of 1,800 doses of controlled substances and a patient who was harmed after being given the wrong medication.

CVS, the nation’s largest pharmacy retailer, has for years been buying out competitors, closing them and then transferring prescriptions from those pharmacies into the closest CVS stores. CVS workers told state inspectors and the Capital Journal that in at least some instances, CVS didn’t add to its already bare-bones staff to handle the extra business.

Severe understaffing at CVS stores seems to have contributed to weeks-long waits to fill prescriptions, lack of proper controls over narcotics, expired and adulterated drugs not being removed from shelves, prescriptions being improperly dispensed and other problems, according to Ohio Board of Pharmacy reports. In addition, the strain of such understaffing has contributed mass turnover at CVS pharmacies, inspectors reported and CVS workers told the Capital Journal.

Reports previously obtained by OCJ found problems at CVS pharmacies in Canton, Dayton, Columbus, Painesville, Toledo, Massillon, Wooster and Reynoldsburg. Then last week, it received inspection reports for CVS store No. 4351 in Willoughby, 20 miles northeast of Cleveland.

One said that on Jan. 13, 2022, a patient picked up a prescription for what was labeled ropinirole, a dopamine agonist used to treat symptoms of Parkinson’s disease, restless leg syndrome and other ailments.

“Patient 1 ingested approximately 27 tablets of the incorrect medication and experienced adverse effects including increased anxiety, rapid heart rate, and sweating,” the report said.

Weeks later, the mistake was discovered.

“On or about February 3, 2022, Patient 1 picked up a prescription refill from the pharmacy and realized the tablets looked different than those she had ingested from the previous bottle,” the report said.

While the initial prescription bottle was labeled ropinirole, it actually contained digoxin, the report said. That’s a drug used to treat heart failure and arrhythmia.

Even after switching to the correct medication, problems apparently persisted. The patient went to the emergency room on Feb. 14, 2022 for “accidental drug ingestion,” but no digoxin toxicity was found, the report said.

A pharmacist approved a prescription he shouldn’t have, but Board of Pharmacy investigators said other safeguards broke down as well.

“The dispensing software permitted the medication to be verified without scanning the bottle or alerting the pharmacist the standard safety procedure may or may not have been completed,” the report said.

Asked about the error, CVS spokesman Matthew Blanchette said in an email, “We have comprehensive policies and procedures in place to support prescription safety. Prescription errors are very rare, but if one does occur, we take steps to learn from it in order to continuously improve quality and patient safety.”

Investigators found other problems at the Willoughby pharmacy.

In April and May of 2021, the store reported the loss of the addictive sedatives lorazepam and diazepam, better known as valium. However, CVS reported in both cases that “the loss was not significant, listing the loss as 0 tablets.”

When the Board of Pharmacy contacted a CVS loss prevention manager, that person said, “the pharmacy was recently remodeled and believed the loss was due to disorganization and inventory control issues.”

Subsequent reports of “Theft and Loss” said that 141 1mg lorazepam tablets and 106 5mg diazepam tablets were gone — considerably more than the zeroes originally reported. And inspectors on July 21, 2021 found conditions similar to what they found in several other CVS pharmacies.

“Agents observed medications spilling off the pharmacy shelving in the back of the pharmacy and numerous medication stock bottles stored on the floor of the pharmacy,” the report said. “Additionally, the pharmacy was observed to be dirty.”

Perhaps more concerning were reports the Board of Pharmacy received from the Willoughby CVS last year:

  • The store reported that on June 9, 2022, it detected the loss of 575 50 mg tablets of the painkiller tramadol.

  • It reported that on April 12, 2021, it detected the loss of 499 2mg tablets of the sedative alprazolam.

  • And on Aug. 24, 2021, the store detected the loss of 479 10mg tablets of the sedative-hypnotic zolpidem tartrate, better known as Ambien.

All of the drugs the Willoughby reported lost are Schedule IV controlled substances and pharmacy workers couldn’t find paperwork that is required in response to losses of them. In addition, as was the case in several other harried CVS stores it inspected, the Willoughby store did not have a Responsible Person properly listed with the Board of Pharmacy.

That person, a pharmacist, is legally responsible for the dangerous drugs in the store and when there’s a change in that position, all such drugs are required to be inventoried. However, amid massive staff turnover, the Board of Pharmacy found several instances in which such a person was improperly designated at Ohio CVS stores, or no such person was designated at all.

The board has the power to fine and reprimand pharmacies or revoke their licenses altogether. A hearing into problems found at a CVS store in Canton is scheduled for the board’s Nov. 7-8 meeting. Others are yet to be scheduled.

Asked to comment on problems found at CVS’s Willoughby store, Blanchette, the spokesman, sent a quote almost identical to one the company sent in response to the lengthy list of problems the Board of Pharmacy found in eight other Ohio stores.

“We’re continuing to work with the Board of Pharmacy to resolve allegations of isolated incidents, most of which date back a year or more,” Blanchette said.


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