I have blogged on this tragic story earlier. In 2006, Emily Jerry was receiving treatment for cancer at a Cleveland Hospital. She was due to leave the hospital after her treatment, and was getting a last round of chemo. However, a pharmacy technician at the hospital mixed the chemo drug with a saline solution that was more than 26 times the prescribed amount. Emily fell seriously ill as a result of the error, and died three days later. 

It’s hard to imagine that anything good could come out of this tragic death, but Emily’s parents have found a way to do just that. They have managed to use their tragedy for the greater good. They spearheaded efforts to pass Emily’s Law which was signed in 2009.  The law requires that prescription errors be reported to the Ohio pharmacy board, and that there be a limit on the number of technicians under a pharmacist’s supervision.

Scott Grossman is a pharmacy error lawyer representing injured victims of pharmacy errors in New Jersey and nationwide.

The concept of having pharmacy chain employees on state pharmacy boards supposedly ensures that these boards have the expertise of seasoned professionals to draw from. While that may be true, it also ensures that the boards are staffed with a number of members who act to protect the interests of the pharmacies they work for. It reduces the concept of an "independent" state board regulating and overseeing the functioning of thousands of pharmacies in a state, to a farce.

Nobody should be too surprised when these board members who have vested interests proceed to veto decisions that are detrimental to the interests of the chain they work for. A perfect example to illustrate the conflict of interest here is the case of Tonya Pearson, a pharmacist at a Jacksonville Walgreen outlet, whose failure to catch a prescription error led to the death of Terry Paul Smith, a construction worker. When the employee came up for disciplinary hearings, a board member who was also a pharmacist at Walgreen, vetoed a fine of $10,000 on the erring Pearson. She got away with a $1,000 fine, and an "education program" to help catch errors – something Walgreen should have put her through before it allowed her to fill prescriptions at their outlet.

Such conflict of interest has riled advocates of better separation between the regulator and the regulated. But, the status quo continues merrily, and the only sufferers are victims of prescription errors like Terry Paul Smith. It's injustices like these that inspire pharmacy misfill lawyers who often turn out to be the only line of defense against well connected, big name chain pharmacies and their widespread sphere of influence. 

The company in question is CVS, which has the highest number of stores – 285 of them - in the state out of all the nationwide chains. According to the report, the distinction with other chains doesn't quite end there. CVS also has the highest number of citations from  the North Carolina Pharmacy Board for prescription errors. In fact, the Board has repeatedly cited the chain for creating a work environment in which employees are likely to make mistakes.

Regular customers who get their prescriptions filled at CVS are noticing the difference in service, the report says. Staff members often seem to be in a hurry to rush through prescriptions. It's not simply a desire to squeeze more out of their workday that's behind this high speed work environment. As the report points out, the company has incentive systems in place that reward employees based on the volume of prescriptions they fill. In fact, CVS pharmacists routinely receive updates on the amount of extra cash they stand to make depending on how quickly they can fill bottles with pills.

The extent to which CVS has been able to continue this practice unchecked, is shocking. Consider these statistics – the Board of Pharmacy stipulates 150 as the number of prescriptions that can safely be filled by a pharmacist in a single day. At CVS, some former employees have gone on record to claim that on a busy day, it's not unusual for pharmacists to fill as many as 500 prescriptions.  

In one complaint of pharmacy error against CVS that was filed with the Board, a pregnant woman took home what she thought was anti-morning sickness medication from her local Salisbury CVS store.   Only, it turned out to be a drug that's prescribed for patients with spinal injuries. When the Board investigated the number of prescriptions that were filled on the day of the potentially tragic mistake – a common practice when pharmacy errors are reported – it was found that the pharmacist responsible had filled 513 prescriptions on that particular day.

CVS itself sees nothing wrong with the speed at which prescriptions are filled at its stores. According to a spokesperson, certain speed is necessary in "specific defined circumstances."   The blasé attitude at CVS towards the concerns of the Board and the public, as well as the company's focus on volume and profits at the cost of patient safety, is appalling. But it's far from an isolated case. The push for profits over safety is common to most of the major nationwide pharmacies. The kind of prescription errors that result when pharmacists are counting the dollars that will be chalked up on their incentive sheets, instead of focusing on the name of the medication they are filling out, should be a cause for worry, not only for pharmacy error lawyers, but also consumers.