Board: Pharmacy error led to overdose, possible death
The Hy-Vee Pharmacy located at 1501 First Ave. East in Newton was recently sanctioned by the Iowa Board of Pharmacy. (Photo via Google Earth)
Several Iowa pharmacies have been cited by the state recently for dispensing incorrect medications, including one instance in which a patient might have died.
The Hy-Vee Pharmacy located at 1501 First Ave. East in Newton, was recently charged by the Iowa Board of Pharmacy with dispensing the incorrect prescription to a customer.
The board alleges that on Jan. 14, 2024, the pharmacy mistakenly dispensed 30 milliliters of morphine concentrate to a patient with incorrect directions on the label, which the board says resulted “in a substantial overdose and possibly early death.” No other information on the case has been made public by the board.
The board has imposed a $5,000 civil penalty against the pharmacy and ordered that the entire professional staff at the pharmacy undergo training on medication errors and patient safety.
Other cases recently addressed by the board include:
— A Hy-Vee Pharmacy at 2827 Hamilton Boulevard in Sioux City, which was charged with dispensing an incorrect prescription to a customer. The board alleged that on Oct. 6, 2023, the pharmacy incorrectly administered an influenza vaccine to a patient who had requested a COVID-19 booster vaccination. The board imposed a $2,000 civil penalty, and the entire professional staff was ordered to undergo training on medication errors and patient safety.
— A Hy-Vee Pharmacy at 351 NE Gateway Drive in Grimes, which was charged by the board with dispensing the incorrect prescription to a patient on May 29, 2023. No other information on the incident was disclosed by the board. The board imposed a $2,500 civil penalty and the entire professional staff was ordered to undergo training on medication errors and patient safety.
— A CVS Pharmacy at 14201 Hickman Road in Urbandale, which was charged by the board with dispensing the incorrect prescription to a customer. The board alleged the pharmacy failed to provide the correct amount of medication to a patient who is a minor. When the minor’s caregiver later requested a refill, the pharmacy – unaware it had initially provided the wrong amount of medication – informed the caregiver no refill or “hold over” medication was available. The patient later suffered a seizure as a result.
While the publicly available board records are unclear as to the chronology of events, it appears the board also alleged the pharmacy made additional, subsequent errors with the same patient – first by filling a prescription for 52 tablets of medication by providing only 51 tablets, and then by shorting the patient 100 tablets of an unspecified medication. The board imposed a $5,000 civil penalty on the store.
— Monroe Community Pharmacy, located at 112 E Washington St. in Monroe, which was charged by the board with failing to reconcile its actual inventory of narcotics with its documented supply, failing to maintain complete and accurate pharmacy records, failing to have adequate policies in place with regard to narcotics, and failing to train pharmacy technicians at a telepharmacy site.
According to the board, the pharmacy determined controlled substances were missing from its inventory in October 2023. An investigation revealed that more than 700 Adderall tablets and capsules of various dosages were stolen by an employee over the previous eight months, and that the pharmacy had no policies in place regarding the physical inspection of and reconciliation for its inventory of controlled substances.
The board fined Monroe Community Pharmacy $3,500 and placed the pharmacy’s license on probation for three years. In addition, the board ordered that the pharmacy staff complete educational training on narcotic theft.
In a separate but related case, Douglas Niedermann, who was the Iowa-licensed pharmacist in charge at the Monroe pharmacy, was charged by the board with failing to audit and reconcile the inventory, and with failing to maintain complete and accurate pharmacy records. The board imposed a $500 civil penalty on Niedermann for the violations and ordered him to complete complete-education courses on controlled substances and theft of narcotics.
— A CVS Pharmacy at 3414 8th St. SW in Altoona, which was charged by the board with failing to complete Drug Enforcement Agency records as to the loss of controlled substances, committing an act that would render its Controlled Substances Act registration “inconsistent with the public interest,” and with failing to submit a form to the DEA within 14 days of the theft or loss of controlled substances.
The publicly available board documents give no indication of what drugs were lost, how they were lost, or the quantity of drugs lost. The board imposed a civil penalty of $5,000 and placed the business’ pharmacy license and its Controlled Substances Act registration on probation for two years.
— DCA Pharmacy of Franklin, Tennessee, which was charged by the board with sending prescriptions into Iowa for two full years without an active Iowa license. Between January 2022 and January 2024, DCA Pharmacy allegedly filled 2,655 prescriptions for Iowa customers, all without the required license. The action was apparently uncovered only when DCA applied for a new Iowa license in January of this year.
In addition, DCA was also accused of shipping compounded progesterone capsules into Iowa, despite its inability to show any of the required evidence of a clinically significant difference between the compounded medication and that which was available otherwise. The board imposed a $5,000 penalty against the company.
As part of a separate but related case, DCA’s pharmacist in charge, West Conner, was fined $1,000 by the board.
Editor’s note: As noted in an earlier version of this story, the Board of Pharmacy’s published decision regarding the Altoona CVS pharmacy gives conflicting information as to the pharmacy’s location, indicating it is located in Ankeny. The board has since confirmed the actual location is Altoona.
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