CVS faces pharmacy reviews

CVS Corp. will undergo outside safety reviews at its 309 pharmacies in Massachusetts as part of an unprecedented state settlement over scores of prescription errors, some of which resulted in patients being hospitalized.

The agreement requires CVS to enter a consulting contract with the Institute for Safe Medicine Practices and submit to two years of ongoing review by the national nonprofit organization.

The unusual action by the Massachusetts Board of Registration in Pharmacy is in response to complaints by consumers who said they received the wrong dosages or medications from CVS pharmacies. In all, the board investigated 80 complaints and substantiated 62 of them, said Jean Pontikas, director of the state Division of Health Professions Licensure.

Pontikas said no one died because of the errors, but some patients did not receive the proper medications and may have suffered unnecessary side effects.

''Some of these were serious medication errors that did, in fact, result in some short-term harm to patients," Pontikas said.

Instead of pursuing actions at individual pharmacies where problems occurred, she said, the state board ''wanted to see improvements across the system." CVS stores account for 28 percent of all pharmacies in Massachusetts.

The complaints included one from the family of a 4-year-old Brockton girl who was supposed to receive a drug for hyperactivity, but instead was given a man's prescription for a drug to treat an irregular heartbeat. The board does not track which patients went to the hospital, but published reports listed at least four other cases that required hospitalization.

Pontikas cited another customer at a CVS in West Roxbury who was prescribed Topomax, a medication used to treat seizures and bipolar disorder, but the pharmacy instead dispensed Toprol XL, a medication for high blood pressure and chest pain. And a patient at a Brockton CVS received Baclofen pills, used to treat symptoms of multiple sclerosis, that were twice as strong as prescribed.

CVS said the 62 cases spanned three years beginning in 2002. The pharmacy chain dispensed 85 million prescriptions in Massachusetts during that time, it said.

''While no process involving human beings is completely immune from error or deviation from procedural controls, we continue to strive for 100 percent accuracy," said Papatya Tankut, CVS's vice president for pharmacy services.

The Board of Registration in Pharmacy said its investigations uncovered a variety of deficiencies at CVS stores: Pharmacists did not always offer an explanation of medications and side effects as required by state rules; drugs with similar names were stocked beside each other; inventory was improperly labeled; and the ratio of pharmacists to assistants was sometimes too low.

The Institute for Safe Medicine Practices will produce the first of a series of reports on CVS's pharmacy dispensing operations after six months. If CVS does not follow the institute's recommendations, its stores could be placed on probation without further notice by the state, under terms of the agreement. The agreement is called ''nondisciplinary," and the state agreed not to prosecute the errors.

State Senator Susan C. Tucker, Democrat of Andover, has submitted a bill that would require pharmacists to report medication errors to the state instead of leaving it up to consumers to trigger reviews through their complaints.

''CVS deserves credit for agreeing to this oversight. Unfortunately, dispensing errors are not limited to CVS stores," Tucker said. ''There needs to be a transparent, comprehensive system for collecting data on medication errors."

Michael Cohen, president of the Institute for Safe Medicine Practices, which has headquarters in Huntingdon, Pa., said pharmacies typically experience a 3 percent error rate. That could include anything from spelling a patient's name wrong to putting the wrong pills in a bottle, he said.

Like other pharmacy chains in the United States, CVS is introducing bar-code scanners and automated systems to reduce errors, he said.

''I know they are doing things like other pharmacies. There is always room for improvement, and I think they recognize that," Cohen said. The institute has examined a chain-pharmacy's safety procedures in an entire state only once before, but he declined to provide details. It also works extensively with hospitals and other health institutions to reduce medication errors.

''There is no place that is 100 percent error-free," Cohen said.

Christopher Rowland can be reached at crowland@globe.com.