A secret crisis is unfolding inside pharmacies in the state and across the country. The struggle to fill an increasing number of prescriptions has fueled growing concerns over harmful and sometimes deadly prescription mistakes.
But Ohio pharmacies and others nationwide can make these mistakes and the public can be kept in the dark, a 5 On Your Side investigation has found, because they are not required to report these errors to state regulators.
Have you ever received the wrong medication or had other issues at the pharmacy? Fill our our feedback form here.
Our findings
State regulators do not maintain comprehensive data on how many people have been harmed or killed as a result of prescription mistakes made by pharmacies.
In an effort to piece together how often these mistakes occur, our team reviewed four years of Ohio Pharmacy Board minutes, court dockets and autopsy reports.
We found there have been at least 491 complaints — filed largely be consumers – involving prescription mistakes. In addition, we uncovered two people were killed and 31 people were harmed as a result of being given the wrong medication at local pharmacies across the state.
Alarmingly, industry experts are convinced those numbers are likely much higher. Our investigation found no one is certain just how many are harmed because pharmacies in Ohio are not required to report those complaints.
‘Try your best not to kill anyone'
At the same time, demand and workload for Ohio’s 20,349 pharmacists and 20,649 pharmacy technicians is growing, according to Ohio Pharmacy Board records.
The Ohio Pharmacists Association, which represents pharmacists and pharmacy technicians, is concerned that 150 local pharmacies have closed their doors and small pharmacies are being bought out by large chains that the association believes fail to adequately staff pharmacies.
“It’s fill as fast as you can — try your best not to kill anyone,” said Antonio Ciaccia, the association’s Director of Government and Public Affairs.
Our investigation found heartbreaking and tragic mistakes:
· Michael James Carmack was just 25 years old when he died in April of 2015 as a result of being given the wrong medication at his local pharmacy, according to the lawsuit that was settled and dismissed, as well as pharmacy board disciplinary reports. Court records reveal Carmack “ingested the wrong medication,” and an autopsy report confirmed “the pills in the prescription bottle did not match the prescription on the prescription label.” The pharmacist “neither admits nor denies the allegations," according to the disciplinary records. However the pharmacy board said it has “evidence sufficient to sustain the allegations” and levied a $3,000 fine that the pharmacist agreed to pay.
· In another case, a lawsuit alleged that 68-year-old Johnny Shepherd died as a “result of pharmacy negligence” after dispensing medication that was “mislabeled.” His wife Molly Shepherd is convinced “the medication killed him.”
“I loved him, and he loved me,” Shepherd said. “[His death] caused me to be miserable, living by myself.”
· Tabatha Gonzalez said she was five months pregnant when she discovered she had been taking prescription medicine belonging to someone else. But fortunately, it turned out to be the identical medication and dosage. Even so, she remembers worrying, “Is my baby going to be OK?” she said.
· The mother of a now 20-year-old remembers how a pharmacy mistake hospitalized her son when he was just 5 years old. Carrie Klein said her son, Freddie, suffered from a rare brain disorder since birth and required medication to control his seizures. “I got a magnifying glass and looked at the pill and sure enough, it was double the dosage,” she said. “They could have killed him.” The mistake was never reported until Klein filed a complaint on her own.
Doing ‘more with less’
Last year, more than 171 million prescriptions were filled at pharmacies across Ohio, according to the Henry J Kaiser Family Foundation. The Ohio Pharmacy Association said, “that number is skyrocketing” while pharmacies are “being forced to do more with less.”
“That is incredibly dangerous,” Ciaccia said. “We should not be sitting around waiting for the next error or the next death to occur.”
Even longtime pharmacists like Ray Carlson are taking the highly unusual step of voluntarily becoming “whistleblowers” to bring conditions inside pharmacies to the public attention. Carlson owns a successful compounding pharmacy in Poland, Ohio that provides specialized prescriptions for patients and hospitals in Northeast Ohio.
“This is very unusual for a pharmacist to not have his face blocked out or his voice garbled,” Carlson said in an interview.
For example, in a highly public move, Carlson took the Ohio Pharmacy Board to court in order to compel the board to survey Ohio’s pharmacies to ensure they were following both state and federal laws governing dispensing.
With Ohio’s growing opioid crisis, Carlson grew concerned over workplace conditions that may be leading pharmacists to be too busy to ask consumers a comprehensive list of questions regarding their medication and drug reactions, among others.
Carlson’s goal was to warn the public of the “impact and danger” if safe dispensing practices were not adhered to, including the potential for errors.
“Absolutely, it leads to errors,” Carlson said. “We know it’s being under reported if not reported at all.”
The case was ultimately dismissed, but Carlson continues to stress that pharmacies appear to be failing to spend adequate time with consumers simply because they are overworked and too busy.
In fact, he said the next time consumers pick up their prescriptions, they should notice the box they check that seems to indicate only that they have picked up their medication. By checking it, he said, consumers are also surrendering their rights to counseling and questions from the pharmacist.
“I can remember when it once took five pharmacies to fill just 100 prescriptions a day,” Carlson said. “Now, you got one pharmacy with two pharmacists doing 500 a day.”
“If I make you do more with less time and less resources—will you do better?” Ciaccia asked. “I don’t think anybody would…I think everybody would actually say they would do worse.”
Pharmacies respond
In a statement to News 5, the National Association of Chain Drug Stores (NACDS), which represents 40,000 pharmacies nationwide, said “while some have attempted to link” prescription errors “with pharmacist’s current responsibilities,” the NACDS warns against a “rush to judgment” or “assume a causal relationship.”
The NACDS also supports “voluntary reporting of medical and prescription errors in a non-punitive forum” as opposed to mandatory reporting without fear of being subjected to lawsuits. You can read NACDS’ full statement here.
NACDS also points to a report by the Institute for Safe Medication Practices that “emphasize strongly the importance of voluntary reporting rather than mandatory as well as findings by the Agency for Healthcare Research and Quality within the U.S. Department of Health and Human Services.
The nation’s two largest pharmacies provided written statements to News 5 but declined on-camera interviews.
A spokesperson for Walgreens responded saying, “Prescription errors are rare and we take them very seriously. In the event there is an error with a prescription, our first concern is always for the patient’s well-being.” You can read Walgreens’ full statement here.
A CVS spokesperson also insisted “errors are rare,” saying the pharmacy “has comprehensive policies and procedures in place” to ensure safety. You can read CVS’ full statement here.
Walmart, the nation’s fourth largest retail pharmacy, said only, “We don’t have anything to add to your story.”
We shared our findings with the Ohio Pharmacy Board that is now promising to move forward with proposed rules that would require mandatory reporting of pharmacy errors.
Pharmacy Board Executive Director Steven Schierholt said the debate has long been that if pharmacist and technicians were fearful of possible criminal charges, it would have the opposite effect and encourage less reporting — not more.
He said the board has been working toward mandatory reporting that would encourage more accurate and full reporting without criminalizing pharmacists.
“The board is in the process of promulgating rules that would require a pharmacist to report instances of reckless behavior that resulted in a dispensing error, or unprofessional conduct that resulted in a dispensing error,” Schierholt said.
New rules regarding mandatory reporting of pharmacy errors will be proposed and released in the next few months.
If you suspect you’ve been given the wrong medication, you can call the Ohio Board of Pharmacy at 614-466-4143 or fill out a form at this link.
Have you ever received the wrong medication? Contact 5 On Your Side Investigator Ron Regan and he will follow up with you: