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Five-year-old took wrong medication for two months

By KEVIN MCCOY AND ERIK BRADY, USA Today
When Tabitha Jones picked up her stepson's medicine at a Walgreens store near Nashville in 2004, she had no way to know the pharmacy was so busy that its manager had asked for more staffing months earlier to "decrease the pharmacist's stress."

She also had no idea the drug Walgreens gave her that day was a steroid never intended for children and not the blood pressure drug prescribed to treat Trey Jones' hand tremors and hyperactivity. Walgreens refilled the prescription four times, eventually at double the adult dosage, before the error was caught. The 5-year-old not only went into premature puberty but also erupted in rages.

Trey's parents sued Walgreens, fearing the steroid could stunt the boy's growth or cause liver damage. "We don't know what could happen later on down the road," his father, Robert Jones Jr., said in a 2006 pretrial deposition.

Pharmacy chains say they've spent billions of dollars on safety technology and other improvements that have cut their prescription-error rates to a fraction of 1%. As aging baby boomers and other Americans increasingly rely on prescription drugs, an Auburn University pharmacy study in 2003 projected the odds of getting a prescription with a serious, health-threatening error at about 1 in 1,000. That could amount to 3.7 million such errors a year, based on 2006 national prescription volume.



A USA TODAY investigation found evidence that corporate policies — such as allowing or encouraging pharmacists to fill hundreds of prescriptions daily and rewarding fast work — can contribute to errors like the one that befell Trey Jones.

CORPORATE POLICIES CAN FOSTER ERRORS: "There is a correlation between workload and errors," retired pharmacist says.

CORPORATE POLICIES REDUCE ERRORS: Recent advancement "has made the pharmacist much more accurate," current pharmacist says.

The investigation reviewed policies and alleged errors at rivals Walgreens and CVS, the nation's two largest drugstore chains, which fill nearly one-third of all retail prescriptions nationwide. It included a review of scores of lawsuits, as well as pharmacy board disciplinary actions in 10 states. Some common factors emerged:

•Too many prescriptions, too few pharmacists. Some stores fill so many prescriptions that pharmacists work long shifts with few breaks. In the case of Benjamin Goldberg, a North Carolina baby whose parents were given an antibiotic with instructions for five times the prescribed dosage, the state pharmacy board reprimanded a CVS pharmacy for filling prescriptions "at such a rate as to pose a danger to the public health or safety."

• An emphasis on speed. American consumers expect fast pharmacy service, and the chains try to meet that expectation. Walgreens guidelines obtained by USA TODAY say pharmacists need as little as two minutes to fill a prescription. That doesn't leave enough time to counsel patients about a new prescription, says William Kennedy, a former Walgreens pharmacist and union leader.

CVS monitors whether pharmacists meet goals for filling prescriptions by promised times and ensuring phones are answered swiftly. The Institute for Safe Medication Practices urged CVS to review whether the policies place"speed above safety" after a Massachusetts investigation substantiated 62 drug errors or other concerns.

• A reliance on technicians. Walgreens and CVS rely on lower-paid, lesser-trained technicians to help pharmacists by processing and packaging prescriptions. Although pharmacists by law must verify that each medication contains the right drug, dosage and directions, they don't always catch technicians' errors. In Jacksonville, roofing contractor Terry Paul Smith died of a methadone overdose in 2001 about 36 hours after getting a prescription for which a dosage error by a Walgreens technician went unnoticed by a pharmacist.

•Pharmacist incentive awards. At Walgreens, bonuses paid to pharmacists and pharmacy managers are based in part on increases in prescription volume. Until this year, CVS partly based pharmacists' bonuses on their success in meeting company goals for filling prescriptions by the times promised to patients and for ensuring phones are answered promptly.

• Counseling gaps. All but two states require pharmacies to offer face-to-face counseling to most customers who pick up new prescriptions. But state records show CVS was cited at least once by the North Carolina Board of Pharmacy for failing to offer or provide counseling, and Walgreens was disciplined at least five times since 2002 for similar infractions in Oregon.

Walgreens provided a demonstration of the high-tech safety systems used in the chain's pharmacies but declined to make executives available for USA TODAY interviews. In written responses, the chain said it has spent nearly $1 billion in the last 10 years on safety training and technology."That investment shows how seriously we take our responsibility to be error-free," Walgreens said, adding that its goal "is to take out the possibility of human error as much as possible and have a zero error rate."

CVS also provided a demonstration of its computer and safety systems. Papatya Tankut, CVS' vice president for pharmacy professional affairs, said in an interview that improvements have cut errors to "a small fraction of 1%," a rate she said is "continuing to decline."

Daniel Hussar, a pharmacy professor at the University of the Sciences in Philadelphia, offers a more critical view. He says staffing policies have made pharmacy chains stressful workplaces. "The emphasis on speed is counterproductive. It's an invitation for error," says Hussar, editor of The Pharmacist Activist, an online newsletter.

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