This showed up in a FACE BOOK POST !
I can’t hold this in one moment longer!! Most of you know for the past few years I basically just share links and a occasional comment…it’s not because I don’t have a lot to say, because those that know me well know my mouth. Tonight I commented on a photo shared by a friend with her little one enjoying a summer evening and knew what I needed to do.
In May,2014 a near deadly error occurred at CVS in PA. A 3 y/o was prescribed oxycodone 1mg/1ml , but medication dispensed was 20mg/1ml.. with the directions for the 1 mg/ml. The child was stat-flighted to the hospital that evening. It’s apparent that the all the red flags during the filling process were ignored.
You would think that this would be a RPH’s worst nightmare, but was it?
Staffing levels are at a all time low…metrics and profits are put ahead of Safety. The Board of Pharmacy does nothing to protect the patient and in PA, errors don’t have to be reported to the BOP as is the case with most states.
So to all my non-pharmacy friends be vigilant when it comes to the medication you are taking and giving as Speed Can Kill !!
I have been aware of this incident for some time.. I know that some attorneys are ware of this, as are some investigative reporters and of course the hospital where this toddler was stat-flighted to and I guess the insurance company that had to pick up the tab for the costs of this “med error”.
It has been reported that this particular RPH was at the end of a 12 hr shift in a 24 hr store and was the end of the RPH’s shift and was hurrying to get out… and entered/processed the entire Rx .. no tech were involved in the processing of this Rx..
It is also been reported that this particular RPH is a real good “CVS METRICS RPH”.. apparently there is not a metric that this RPH doesn’t try to meet or beat.
On the surface.. if this particular CVS pharmacy has a Rx on file for Oxycodone 1mg/1ml and Oxycodone 20mg/1ml was dispensed.. doesn’t that mean that this store’s C-II inventory is OFF ?
Since this incident.. I have been told that CVS has implemented a new automated scheduler referred to “MY SCHEDULER” and that Rx dept hours have been CUT AGAIN across the chain.
Is this another incident of a RPH working 12-14 hr shifts without any scheduled breaks contributed to this “incident”.. of course, I have yet to see a Pharmacy Board acknowledge that long shifts, under staffing and other work environment issues can impact safety and the number of med errors ! But then, the 51 BOP’s primary charge is protecting the public’s health and safety.. it would appear that the PA BOP.. may deserve a “F” on their report card. but then.. political appointees are exempt from being sued for failing to do their job.
Filed under: General Problems
Really CVS…if there was one RX you should have got right, it was Joe Zorek’s !!!
#assclowns …and the errors follows on store to store transfers.
My Husband was told years ago when he asked the Pa BOP why they weren’t doing anything to try to make Insurance Comany’s reimbursements fair and equal, among other things, and was told that it “wasn’t their job to make sure he could make a living being a Pharmacist”. Makes me wonder if they too aren’t included in kickbacks.
The RPh that filled this RX is the PIC…bypassed DUR’s…and is all about the metrics. He has been on the bureaucrats radar in the past for professional conduct and more…also the PIC while multiple script pro contaminations were made
The problem, people, is that we did this to ourselves. We have encouraged the behavior of the big, bad, evil chains because we were greedy and wanted more time off. To stand up now and say it is CVS, WAGS or any other chains fault is insane. Stand up for yourself. Demand that the chains follow labor law and don’t buy into this exempt employee bull. I worked for a chain that used to call us “hourly-salaried” employees and they were therefore not obligated to give us breaks or lunches!! Seriously??? The DM’s are home with their families, as are most of the Dr’s but we cant find the time to take a leak. Don’t depend on the BOP to help either. Why? Who is on BOP? Here in the state of confusion the BOP is comprised of the DM’s for the chains. The are not in any way interested in making your life better, if it compromises their pocket. Besides the BOP is there for public protection and safety. Sounds like it doesn’t it? How is it that we are the ONLY “profession” that never gets to take a break, or that is required to work 12-14 hour days with no help? Pt safety is a pipe dream in the present environment. We have no lobby power at all. The best possible thing that can happen is to unionize and collectively bargain for better, safer and more intelligent working conditions and overtime. The problem with us pharmacists is that by nature we are, for the most part, spineless. We cede control of our profession to the screaming idiot patients, to the screaming idiots that run the Dr’s offices, the Dr’s themselves and even worse to the greedy fools at the top of the corporate food chain.
For shit sake folks we have allowed ourselves to become McDonalds. When did it become the standard to have a DRIVE-THRU at a pharmacy??? Who out there thinks we are going to get respect with a DRIVE-THRU? Anyone? Why do I hear crickets??? The BOP has the power to stop this in the name of public safety and what do they do?? Again, crickets.
The bottom line is that if we as a profession do not take control of our profession back, the only way to make things better for us is to unionize. We will have to decide if we want to be common employees or professionals. Amazingly the common employees, techs, clerks, cashiers, baggers, and all of the other employees in the store have the right to take a break, take a lunch(without working), get paid OT when they work more than 8 hours a day, 40 in a week, or for the 6th day in a week. Does anyone out there find it interesting that a high school drop-out at a Dr’s office can call in prescriptions but only a pharmacist can take them? My favorite happening is when a pt calls his/her Dr office for renewals that they tell the patient to call the pharmacy and have them call the Dr. What is that?? Once again proving my point that we have no control of our own profession. We are basically there to protect the overpaid, underworked prescribers from themselves and when they absolutely demand we fill their badly written Rx for the pt and something happens we get hammered. They can amputate the wrong leg on a pt and walk away unscathed, save for a few dollars that their malpractice insurance will have to pay. We on the other hand would get the electric chair for giving Lasix 40mg by mistake for Lasix 20mg.
Sorry guys, but 30 years in this business has given me a bit of a bitter taste and regretting not going to medical or law school.
At some point the employee has to stand up and say enough is enough. I don’t know a pharmacist whoever became a pharmacist for the metrics or long hours. Its our profession. We can either define it or have someone else define it for us.
Spot on Ray W. Any break in retail pharmacy means you get to eat your lunch, as long as the label printer is printing, pill tray is chattering, and the cash register is ringing. It does not mean you stop the production process.. MA BOP does limit the RPh to max 12 hour shift, which works if you are only open for 12 hours / day. Extended hour stores, who knows when your replacement will show up.
NC has a 12 hr shift rule and >150 Rx/shift is dangerous.. and they enforce NEITHER.
It seems as though CVS wants to get rid of most of the older , independent thinking pharmacist that are not intimidated by their management personnel. And ,instead, hire the younger pharmacist that have recently graduated and that are easily manipulated. This is my personal opinion and I fill that the customer’s needs take a “back-seat” to corporate interest.
Most BOPs I know are in the back pocket of the big chains and will rubber stamp any request they make. Here in FL they are making a push to move the tech to RPh ratio from a max of 3:1 to 6:1. All at the request of CVS, Walgreens, etcetera. I wonder where the patient’s desires and public safety figure into that equation? That is pharmacy’s last hope, if BoP’s would do their job and put public safety first and not the chains bottom lines.
The last time that I looked at the FL BOP.. all members were non-practicing Pharmacist – corporate employees and only one – that worked for WAGS – I could not tell if this RPH was a practicing RPH or a non-practicing pharmacist.,,but his/her paycheck came from a corporation. But when you have BOP members.. that are typically appointed by the Governor… the appointee has to be pretty politically connected or your employer is and/or a sizable contributor to political election/re-election campaigns. From my experience in FL.. the “good ole boy network” is alive/well and thriving …
I might add I told my son to stay out of all PA CVS’s 😀
Peon is spot on the regs on truck drivers. My oldest is a outbound dispatcher for a major trucking firm (Ironically currently working in PA). We discussed the regs. He said their drivers do not unload and if they get to a place and there is no one to unload (ie late) and driver is too close to having to take required ‘off’ time, he has to leave and delivery is done next day. Imagine being ‘forced to take a break’ in pharmacy. 🙂 I used to work for CVS for a short time, half the time you didn’t know if you were coming or going. I would have nightmares wondering if I made a mistake to the point I got physically ill. I don’t get where these studies are coming from that don’t correlate pharmacy’s increasing error rates with decrease in quality of the working conditions….HELLO!!!!!!!!!!!!!!
The RPh in this case didn’t assign a whole lot of meaning to his error….business as usual!!!
When I work, I work 10 hours with a 1 hour break for lunch. My brain is about fried by the end of the day. I cannot imagine working 12 to 14 hours. There are federal regulations for truck drivers to limit the amount of time they drive before taking a rest break. Why? Because they were going asleep at the wheel and killing people. When will the BOP’s and federal government realize that pharmacists are no different than truck drivers and need(must) have a break after working something like 8 hours or they will kill people? If the BOP’s are suppose to be protecting the public, then they should follow the example of the federal government and truck drivers and limit the hours that a pharmacist can work. This working 12 to 14 hour shifts is totally CRAZY!!! We have become ‘peons’ for these huge corporations. The only thing that the corporations understand is the bottom line and lawsuits. They will only change their ways when the amount of money paid out in lawsuits exceeds the gains they make from working people 12 to 14 hours per day. Sometimes, I think these chains are run by a bunch of morons. They have no sense of perception of the ‘big picture’. They get bogged down in metrics and minuscule profits at the expense of treating employees like slaves. It will all come back to haunt them!
Being a retired pharmacist, I still have nightmares of working a 10 to 12 hr shift. I had a 1/2 hr lunch break that usually became a 10 minute one if I was lucky. Management stinks from the Head. It is a rotten job and If I had to do It all over, I would pick a better profession. Money rules and people are unimportant. We are respected by our customers, but not by authority. Mistakes are made, but no matter how tired you are, you must be cautious especially when dealing with narcotics and especially children.
If you feel so “out of it” send the script to another pharmacy.
Right on the point! They don’t care about the employees anymore. They want the stock holders to be happy and so they can remain on the board of directors.
Professional staff may need a union to standardize staffing to a safe level. What was the costly outcome to that poor child? Could you please tell us? Banding together helped nurses either unionized or belonging to national organization that has fought for training, safety and better hours? Perhaps that would help the pharmacist also. I would hate to have this on my conscience. I have seen mistakes by pharmacists both outpatient and inpatient. Thanks for sharing this.
The story that I have heard (rumor on the street) this toddler was being discharged from the hospital with this Oxycodone Rx.. reportedly, the toddler had previously experienced a burn – what degree and per-cent of body unknown – this Oxycodone Rx was a discharge order. Toddler was stat-flighted back to medical center.. don’t know what cause parents to make the call.. the Rx was filled 20:00-21:00 ..so it was bedtime for the toddler.. At this point, it is believed that the toddler survived.. but.. collateral damage from the overdose is unknown
Appreciate the update. It might be years for damages to show. What a nightmare for all involved
Starwood500 you make a good point on here about banding together. Not sure how I feel about a national union other than if there were one I’d probably join it. Banding together through national organizations will help us be heard at both the state and federal level. Problem is we do not have a unified voice and it is not loud enough.
BOP’s also need to start looking at reimbursement rates. It’s not safe when there isn’t enough margin to safely process the prescription. The third party payors have a role in this as well. Think about it, why has staffing been cut so much while our workload increases while all of these prior authorizations and insurance issues distract us from focusing on our patients. Their greed is squeezing us to death while harming our patients. Once it was a privilege to be a pharmacist in the community setting…..not so much any more.
Pa Bop Will Tell You They Have No Jurisdiction. SadRph. Not Their Problem Pay Your LicenSe Renewal Fee And Move Along.
“End of shift” is a very risky time for errors.
This store also has a history of script pro errors!!!
Joe Zorek’s old store… CVS 1917 Harrisburg PA