Human error is inevitable, but pharmacy malpractice is a bitter pill to swallow.

All the sizing up of health care has made talking about it a political abstraction — a nimbus obscuring facts with opaque political ad-copy.

For practical purposes, we might say pharmacies are a kind of moot point amid all this. Despite how you feel about private or pre-paid, nobody calls pharmacies superfluous: medicine will always be dispensed. The pharmacist remains one of the most relatable, accessible parts of the system — approachable without an appointment, responsible in the most immediate sense for regulating your health care.

The pharmacy is incontrovertible in existence, but in effect, sometimes goes unquestioned in practice:

In 2009, Santa Barbara resident Charles Stevens was prescribed an anti-diarrheal medicine, Lomotil. Stevens, 70, went to fill the prescription at the CVS pharmacy on upper State Street where the store’s pharmacist, Caroll Petrin, allegedly provided him with a bottle of Warfarin Sodium, a blood-thinning medication. Stevens, already on a blood thinner, reportedly suffered massive bleeding and was rushed to Santa Barbara Cottage Hospital by his wife.

On June 3, Stevens and his wife, Ada, filed a lawsuit against CVS for negligence and pharmacy malpractice. Stevens is now more or less recovered, except for a bluish skin pigmentation and sensitivity on his chest area.

Dispiritingly, there are a host of pharmacy malpractice suits reporting wrong prescriptions and wrong doses.

Technician training requirements vary by state but all states abide by the same age and education requirement: technicians must have a high school diploma or have a General Education Development (GED) equivalent, as stipulated in Section 4202 of the California Board of Pharmacy’s Lawbook.

The Lawbook also stipulates that a pharmacy with one pharmacist can only have one technician. And for every additional pharmacist, two technicians are allowed. Exempt from this rule are technicians performing “clerical functions.”

Customer service insists on speed. CVS must keep up with the influx of patients, and there appears to be a shortage of PharmDs, a degree that usually requires five years of postgraduate work.

CVS was unable to disclose their ratio of technicians to pharmacists but shared that CVS technicians were trained in a three-tier curriculum. (Efforts to obtain any other information about the technician and pharmacist training programs were unsuccessful.)

The media contacts at CVS corporate were unable to speak about Stevens’ case, as to be expected with an internal, ongoing investigation.

I was able to speak with Stevens’ lawyer, Tyrone Maho of Maho & Prentice, who reports that in their conversations, CVS admits to wrongdoing. “I can tell you we asked for more than $200,000, because you expect to negotiate down,” Maho said. Maho cites a very similar case in 2005, which settled for $200,000, wherein an anonymous plaintiff filed against an anonymous drugstore in Virginia.

In this case, the plaintiff, 61, was prescribed 10 mg/day of Coumadin and was erroneously provided with 25 mg/day, causing massive hemorrhaging and emergency hospitalization. After being released from the hospital, the plaintiff suffered two more hemorrhages and hospitalizations. He sought damages for pain and suffering.

Other cases, easily searchable online, attest to similar complaints against CVS and Walgreens. The Web site of Pritzker-Olsen Law gives two CVS case studies. In one, a claimant’s prescription for a diuretic was erroneously filled with Methotrexate, a high-risk medication sometimes advised for patients with life-threatening cancer. The claimant unknowingly took the Methotrexate for 13 days and was irreparably harmed. The suit asked for $20 million and settled for a confidential amount.

In the second case, a multimillion-dollar jury verdict, the claimant is a kidney transplant patient who, instead of receiving the prescribed 250 milligrams of prednisone (a steroid), was provided 1,250 mg. The claimant was permanently injured.

Categorically, pharmacy malpractice breaks down into either “wrong dose” or “wrong prescription” suits. In Stevens’ case, however, there’s a wrinkle, what Stevens’ lawyer calls a double-error.

The first error, Maho said, was misreading the prescription. The second error a failure to analyze the patient profile, which has a record of all the patient’s medications (at least the ones dispensed out of CVS). It’s a mechanism designed to prevent dangerous combinations and double-diagnoses. A close reading, he said, could have prevented the pharmacist from giving Stevens the blood thinner, a different brand of which he was already on.

The Web site of Steigerwalt & Associates references a study that concluded, “Pharmacy malpractice cost Medicare beneficiaries almost $887 million in 2005.” The Web site also reports that more than 1.3 million people a year are injured because of pharmacy errors.


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