Back when most all State Pharmacy Practice Acts were codified into law, each pharmacy had to have a designated pharmacist as Pharmacist in Charge (PIC) and responsible to the board of pharmacy for making sure the pharmacy observed and adhered to the state’s Pharmacy Practice Act laws. Typically, since most pharmacies were independent pharmacies, the PIC was the pharmacist/owner of the pharmacy. Back when I opened my independent pharmacy in 1976, some 75%+ of all pharmacies in the country were independent pharmacies. I can remember a time when some independents were “Walgreen Agency stores”, I forget exactly when, but Walgreen canceled all those “agency ” contracts and then started expanding the company-owned pharmacies. At one point Walgreens was claiming that they were opening a new pharmacy every 15 HOURS – 7 days a week. They projected that their “saturation point” would be 12,000 stores. At one time they got up to 10K and now they are down to 8K stores.

Along the way, many states changed the term “Pharmacist in Charge” in the state pharmacy practice act, to “Responsible Pharmacist”. Maybe this was done at the request of chain pharmacies when they surpassed having > 50% of community pharmacies.  So these Pharmacists were responsible for everything going right – or – wrong in the Rx dept, but IN CHARGE OF NOTHING!

What’s Gone Wrong at Pharmacies? A CVS Store in Virginia Beach Holds the Answer

https://www.barrons.com/articles/pharmacies-medication-mistakes-cvs-e405367a

As pharmacist-in-charge—an official designation in Virginia—regulators expected Ward to have full control over the pharmacy. But neither Ward’s accomplishments, nor her status on a state permit, were enough to get the resources she believed were needed to run the pharmacy safely, mainly the budget for more staffing hours. Records reviewed by Barron’s show Ward at odds with corporate calculations that cut staffing in her store, despite the fact that the number of prescriptions filled there was on the rise.

When Ward ultimately resigned from CVS in early 2020—after three years at the Virginia Beach store—she sent a warning to the state’s pharmacy regulator. A note, written on her state permit, said she was leaving her position because of “dangerous working conditions due to corporate greed which resulted in sweatshop conditions.”

That note spurred a state investigation of the Virginia Beach store. A sample of 200 prescriptions reviewed by a Virginia inspector found a 37% error rate—some of those mistakes had the potential to harm patients, state regulators determined. Staff members described other errors to state officials, including one that sent a pharmacy customer to the hospital emergency room with an allergic reaction. Employees testified that they understood remarks by the store’s district manager as a threat to their jobs, and that they faced rising pressure to do more with less, including making customer calls required by CVS—even as their queue of unfilled scripts piled up.

CVS’ own store records showed that pharmacists at its Virginia Beach store logged 13 errors, such as “wrong dr-g” or “wrong strength,” between October 2019 and April 2020.

The investigation culminated in a $346,250 fine against CVS from Virginia’s pharmacy board in March 2022, as well as an indefinite probation for the Virginia Beach store. CVS has appealed the board’s order.

CVS declined Barron’s request to discuss specifics of the case, citing the continuing litigation.

The company is “committed to ensuring there are appropriate levels of staffing and resources at our pharmacies using a combination of staffing, labor hours, workflow process, and technology to do so,” a spokeswoman said in a statement to Barron’s.

The company spokeswoman said CVS has an “excellent safety record” and that dispensing errors are rare. “When we learn of a prescription error, the first priority of our pharmacy teams is caring for the patient, taking steps to correct the error, working with the patient and the prescriber,” she said.

Over the past several years, staff at chain pharmacies nationwide have sounded alarm bells about low staffing levels and grueling working conditions. This past fall, those concerns captured national headlines when some pharmacists staged walkouts across the country just as the busy vaccine season was under way.

Nearly 66% of pharmacy professionals reported burnout in 2022, according to the Well-Being Index, a survey developed by the Mayo Clinic, and 73% reported emotional problems—higher than rates for physicians, nurses, and medical students.

“I’ve made dispensing errors that I’ve caught. It’s not a matter of if, it’s just a matter of when,” says Catherine Cooke, a professor at the University of Maryland School of Pharmacy who studies medication safety. “We do need to think about the conditions in place that are contributing.”

Pharmacists have submitted anonymous reports on workplace conditions over the past two years to a portal launched by pharmacy trade associations. In the latest quarterly data, nearly 20% of reports included a near-miss medication mistake and 4% reported an error that resulted in patient harm.

In 2022, 82-year-old Jon Williams had recently been hospitalized in Florida and diagnosed with subdural hematomas—bleeding on the brain—when he and his wife went to their local CVS for his prescriptions, according to a lawsuit. Instead of receiving his prescription, he was given one intended for a “Johnny Williams,” the suit said—Eliquis, a blood thinner that can increase bleeding risk. After taking the wrong medication, the suit alleges, Williams suffered severe headaches and the hematomas grew in size, requiring surgery.

Williams returned home, but was hospitalized again that summer, and experienced a change in speech and a facial droop, according to the suit. CVS denied claims that it was negligent. The two sides agreed to settle in November, according to court records. CVS wouldn’t comment on the matter to Barron’s, and an attorney for Williams said he had no comment.

It’s difficult to get an industrywide picture of how common pharmacy mistakes have become. “There really isn’t good data about how many dispensing errors are occurring,” says Nancy Lewis, a researcher who co-chaired an American Public Health Association task force on medication safety. In 2021, the group estimated that nearly 2.3 million dispensing errors a year—roughly 6,200 a day—could potentially harm patients.

One factor clouding the issue is the use by chain pharmacies of so-called patient safety organizations, where data about mistakes are collected for analysis, but are typically kept private and cannot be subpoenaed.

The pharmacy industry is regulated by state boards of pharmacy, which are composed of pharmacy industry professionals—appointed by a governor—who monitor licensing and the practice of pharmacy. They have not historically imposed rules on how pharmacies must be staffed, though that is beginning to change in some states, including California and Virginia.

That’s part of what makes the Virginia pharmacy board case triggered by Ward so unusual. After two hearings, the pharmacy board issued its six-figure penalty against CVS—its largest in recent years—in March 2022. The Virginia Beach store’s indefinite probation meant that it is subject to unannounced inspections and required to submit quarterly reports on the number of staff hours and prescriptions dispensed every week. The board declined to comment further on the case.

In appealing the judgment, CVS called the fine “grossly disproportionate,” disputed the board’s prescription error data, and said “not a single patient was harmed due to any CVS alleged wrongdoing.” CVS also insisted that the board failed to explain how it calculated the penalty.

The case produced more than 1,000 pages of records and transcripts reviewed by Barron’s, the full extent of which hasn’t been reported previously. It’s a rare glimpse inside the way the pharmacy industry’s troubles have played out at the store level. Employee testimony at a state pharmacy board hearing in 2022, and Barron’s conversations with individuals involved with the case, show a pharmacy staff that felt frustrated and overwhelmed, district management that appeared unable or unwilling to address their concerns, and corporate decisions on staffing that seemed untethered to conditions at the store.

Ward, the CVS pharmacist whose complaint spurred the investigation, worried about speaking out. But she saw the situation in the pharmacy as untenable. “It was all about the hours. It was all about the money,” she tells Barron’s.

CVS #8302 on General Booth Blvd. in Virginia Beach is tucked into a leafy parking lot at the corner of a busy intersection—one of the more than 9,000 U.S. locations operated by the country’s largest pharmacy owner by revenue.

Despite the ubiquity of CVS, its retail pharmacy business has become an increasingly challenged business. The rising power of pharmacy-benefit managers, or PBMs, which control the amount pharmacies are reimbursed for the dr-gs they buy, has eaten away at store profit margins across the industry, even at CVS, which owns a PBM.

In 2023, CVS’ pharmacy segment accounted for roughly one-third of CVS’ $358 billion in revenue. Total prescriptions climbed to nearly 1.65 billion. While CVS’ pharmacy revenue rose 7.5% last year, adjusted operating income was down 8.7%. The company is in the midst of a three-year plan announced in 2021 to close 900 stores and shift those prescriptions to other CVS locations nearby.

The realities facing pharmacies were on full display at CVS’ investor day in December, when the company forecast lower pharmacy profits in 2024—and unveiled a new reimbursement model to shore up the retail side. “It’s time for us to chart a new course,” CEO Karen Ly–h said at the event. Executives reiterated CVS’ approach of the past decade: growing prescription volumes, improving operating efficiency, and selling lower-cost generic dr-gs, while “elevating the levels of safety, quality, and service to our patients,” said chief pharmacy officer Prem Shah.

Staff at the Virginia Beach store describe a different reality, telling state officials that corporate priorities put customers at risk. According to Ward’s testimony, despite being responsible for the pharmacy, she had no control over its staffing, which had proven inadequate given rising volumes. During Ward’s time at CVS, her Virginia Beach pharmacy was open 24 hours. The store typically had one pharmacist on duty, assisted by pharmacy technicians, whose budgeted hours could fluctuate week to week. In 2019, Ward’s team filled 11,000 more prescriptions than the prior year, while working with 1,500 fewer technician hours, according to records and testimony in the case; prescription volume rose 9% during 2019 as technician hours decreased 12.5%.

Victoria Ward, a former CVS pharmacist, resigned in early 2020. She later testified about poor working conditions at her store. Source: Virginia Beach Circuit Court  Staff in the pharmacy department tried to “root each other on” during difficult days, Ward testified. Still, the combination of too few workers and too many demands took a toll, employees told state officials. Some patients yelled when prescriptions weren’t ready. It could be hard to concentrate. After a holiday shift with only two people on duty, one technician said she “went home and cried her eyes out.”

The tone coming from a new district leader, who started in 2019, also troubled employees. During a staff conference call that July, he referred to recent layoffs at a competing pharmacy chain and said CVS pharmacists should be “happy” to have jobs, according to multiple accounts; staffers said they interpreted his comments as threatening their job safety. The impression he gave was that “pharmacists were basically replaceable, expendable,” one staffer testified.

In addition to filling more prescriptions with decreased staffing, Ward said that performance metrics set by CVS’ corporate office took workers’ focus away from the pharmacy counter. Her staff was required to make more than 100 “patient care queue,” or PCQ, phone calls each week, asking customers to refill prescriptions. An employee had to make three attempts to reach a patient, Ward said, and was required to do so even when, in her judgment, the patient was unlikely to need a refill yet.

Ward says that when she prioritized filling patient prescriptions over making PCQ calls, she would “get in trouble” with her district leader. “I would get text messages saying, ‘Hey, this is unacceptable. Why are these calls so low?’” she says. On Saturdays, when only two employees were scheduled to work, they had to juggle the PCQ calls on top of pickups, drop-offs, and the “drive-through going crazy,” said Ward.

Still, there was little Ward could do about the number of staffing hours budgeted. If she tried to add staff time to the scheduling system, she said she would get a message from a corporate employee telling her to cut hours. When she objected to a 70-hour reduction the week of Thanksgiving 2019, her district leader forwarded a note from CVS’ corporate scheduling team: the hours “are accurate based on labor budgets and recent script results.”

Later that month, Ward told her district leader that the pharmacy was “incredibly behind.” She texted, “Is there any way I can get a few extra hours to catch up. Not asking for much.” The manager responded: “Unfortunately there’s a clear message to stay under hours week to week, that’s what we’re given and expected to use to get the work completed.”

When pressed by a state inspector, CVS offered limited details about the scheduling system. In response to a state subpoena for policies and procedures on scheduling, a lawyer for the company said, “CVS does not have policies related to pharmacy scheduling.” The lawyer said, “hours are determined by CVS’ Workforce Management Team,” a corporate group, and that guidance on hours reflects “a number of factors,” including budgeted prescriptions and “recent trends.” The pharmacist in charge doesn’t determine the number of staffing hours needed “in part to lessen the burden of his/her administrative tasks,” the lawyer said, and because he or she “does not have access to all of the factors used to determine and plan for anticipated workforce needs.”

An excerpt from Victoria Ward’s testimony to the Virginia Board of Pharmacy in February 2022. Source: Virginia BEach circuit Court
Ward told the pharmacy board she was never given an answer to the question of why her staff hours were shrinking as prescription volume went up. With her team filling about 500 to 600 prescriptions a day, she said, they were left open to “a lot of potential mistakes.”

In its appeal, CVS referred to the characterizations around staffing levels as “subjective opinions of a small handful of pharmacists and technicians.” Virginia has since issued new pharmacy staffing regulations aimed at preventing fatigue and distraction.

CVS told the state inspector that it reports mistakes to a private entity called a patient safety organization. PSOs, authorized under a 2005 law signed by President George W. Bush, were created to encourage healthcare providers to report and learn from mistakes. As an incentive to disclose mistakes, the legislation granted confidentiality protections for information reported to a PSO. The law gives latitude for how these PSOs are controlled and operated; CVS in 2014 established a PSO called Enterprise Patient Safety Organization. Virginia law allows companies to use PSOs to satisfy the state’s own obligations around analyzing prescription errors.

During Virginia’s investigation, CVS cited the confidentiality provisions of the federal law in declining to provide additional information about dispensing errors.

CVS told Barron’s it encourages staff to report errors without fear, which “allows us to learn from our mistakes and work to continuously improve our systems to support pharmacy teams in providing patient care, in partnership with our PSO.”

But pharmacy employees said understaffing contributed to mistakes. Multiple employees said that one patient was dispensed 100 extra tablets of Percocet, a schedule II na—–c. Ward testified that she discovered the error when she noticed the store’s inventory counts were off. She said she called the patient, and another staffer testified that the patient didn’t want to come back to the pharmacy to return the extra amount. According to Ward, she asked CVS if she should report the incident to the Dr-g Enforcement Administration, as is required when controlled substances are lost or stolen. “I was told by corporate not to, because we know where it [the medication] is,” Ward testified.

The Virginia pharmacy board cited the Percocet error in its final ruling. CVS, in its appeal, said two staffers who reported the incident to the state investigator had no firsthand knowledge of the event.

In another incident, a pharmacy technician said that in 2019, a customer came to fill a prescription for his son on a night when the pharmacy was “slammed.” The father was given the wrong dr-g, according to the staffer, with consequences: The “son had an allergic reaction and was taken to the emergency room.”

Afterward, the father “didn’t sue or complain,” the technician said. “He felt bad for the CVS staff.”

Pharmacist Kellye McNulty recalled working Thanksgiving Day 2019—the week of staff cuts that Ward found extreme. McNulty says she had to work alone part of the shift and almost walked out because it was so stressful. A CVS lawyer at the pharmacy board hearing said a different pharmacist was listed to work that day and a technician was scheduled to be on duty; McNulty testified that she switched with the other pharmacist and the technician didn’t stay the whole time.

McNulty had taken shifts at more than two dozen CVS pharmacies in the area. She considered all of them to be understaffed. When she came to Ward’s pharmacy, McNulty said she ran around enough to break a sweat. “You go fast, you just get it done, and you are going to hurt somebody,” she told the state pharmacy board. “It’s just a given. And as a pharmacist, that’s your worst fear. Corporate will survive if they ki-l somebody but is a pharmacist going to?”

Signs outside a CVS store in Virginia Beach. In 2022, the company instituted a national lunch break for most of its pharmacy counters. Photograph by Jeremy M. Lange
The issue of insufficient breaks for pharmacy staff frequently came up in the Virginia testimony. In 2022, CVS implemented a national lunch break for its pharmacies, with most store counters closing from 1:30 to 2 p.m. daily.

In December 2019, in Ward’s final months on the job, her frustrations spilled over during a store visit with her district leader and a regional loss-prevention manager. “I told them that someone was going to die with these working conditions,” she testified. The visiting manager told Ward that her district leader was “not the one to blame” about the schedule, and that “this is from corporate,” according to her testimony.

The district leader, who was later replaced, told the state inspector that he didn’t recall the specifics of the exchange. CVS didn’t make the loss- prevention manager or four other corporate employees available for interviews with the state inspector.

Ward believed she’d done all she could do. She gave her two weeks’ notice in January 2020.

When the Virginia pharmacy board heard the case in February 2022, Ward was one of the first to testify. She says it was scary to face CVS, but also: “I knew I had a point.” The proceeding stretched well into the night. Two technicians who testified that day had left pharmacy work behind for another industry. One of the board members who voted to penalize the company for understaffing was himself a former CVS district leader, who worked more than 30 years at the company.

McNulty stopped taking shifts at CVS early last year and said she is no longer employed there. She still works at a hospital pharmacy in Norfolk, Va. Despite the stressors at CVS, she says she kept working there because she loved talking with patients and explaining their medications to them. Some nights it felt like she had groupies. But there’s no love lost for CVS. The fine the company received in the pharmacy board case? “Coffee change,” she says.

Filed under: General Problems