Several Ohio CVS pharmacies are under investigation by the state pharmacy board for problems that led to thousands of controlled substances being lost and patient harm after a wrong medication was given, the Ohio Capital Journal reported July 24.
The latest inspection reports found many of the issues were related to "severe understaffing" at the pharmacies. A recent report for a CVS pharmacy in Willoughby found 1,800 doses of controlled substances were lost and a patient was harmed after being given the wrong medication.
On Jan. 13, 2022, a patient picked up a prescription for what was labeled ropinirole, a drug to treat symptoms of Parkinson's disease, according to the Capital Journal. The patient took approximately 27 tablets and experienced adverse effects before the mistake was discovered a week later when the patient picked up a refill and realized the tablets looked different than before. It was discovered the original bottled content digoxin, which is used to treat heart failure and arrhythmia. Problems persisted even after the medication was corrected, and the patient ended up in the emergency room Feb. 14 for "accidental drug ingestion," but no digoxin toxicity was found, according to the report.
The pharmacist and dispensing software failed to verify the bottle's contents before it was given to the patient, the board said, and safety problems continued as roughly 1,800 doses of Schedule IV substances were found missing.
Between April and May of 2021, the store reported a loss of zero lorazepam and diazepam tablets during the remodeling process for the pharmacy. However, subsequent reports found 141 lorazepam tablets and 106 diazepam tables missing. The pharmacy also reported 575 tablets of tramadol missing in June 2022, 499 tablets of alprazolam missing in April 2021 and 479 tablets of zolpidem tartrate missing in August 2021, the Capital Journal reported.
The pharmacy was also found to lack in general standards such as having a responsible person properly listed with the board.
"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, according to the Capital Journal. "Additionally, the pharmacy was observed to be dirty."
The board can fine and reprimand pharmacies or revoke their licenses for infractions, and of eight CVS stores with violations, only one has been scheduled for a board hearing.
CVS spokesperson Matthew Blanchette said in an email to the news outlet: "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. 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."