[Editor’s note: Last year, in a story that referenced worrisome examples from North Carolina, the New York Times reported on how insufficient staffing has brought about big problems at American chain pharmacies that are endangering public health.
This morning, in a new report for the Virginia Mercury, reporter Kate Masters relates similarly troubling developments from our neighbor to the north at a chain pharmacy with hundreds of outlets in North Carolina.]
Understaffing at some CVS pharmacies in Virginia has put patients at risk, former employees say
One location in Virginia Beach was fined $470,000 for serious dispensing errors. Pharmacists say its a systemic problem.
Over the last two years, employees at a CVS Pharmacy in Virginia Beach have raised repeated concerns over patient safety.
At one point, multiple pharmacy technicians told a state inspector that a pharmacist at the store had mistakenly given a patient a hundred extra doses of Percocet — a powerful prescription opioid. Another customer received an antibiotic despite a known history of not tolerating the drug and was taken to the emergency room after an allergic reaction.
In another instance, a patient received the right medication with the wrong instructions, according to another pharmacy tech, who said the oral cholesterol drug came with directions to insert the pills vaginally.
The root of the errors, employees said, was chronic understaffing and an unsustainable workload that made it impossible for pharmacists and technicians to focus on their jobs.
“The pharmacists cannot properly concentrate because they have so much to do,” said Kristopher Ratliff, a member of Virginia’s Board of Pharmacy, reading from a more than 600-page investigative report produced by state regulators.
“A staff pharmacist stated hours had been cut to the point where she didn’t know how the pharmacy was supposed to function,” added Mykl Egan, the board’s discipline case manager, reading from the report. “A fourth pharmacist described the pharmacy as a ‘sweatshop.’”
The findings, which covered a single CVS store, resulted in a $427,000 fine for the chain and one unannounced inspection within the next 12 months. CVS “respectfully disagree[s]” with the board’s order, according to spokesman Mike DeAngelis, and is “considering our options” for potential next steps.
But news of the investigation came as no surprise to former CVS employees in Virginia, who said working conditions were so bad that they had affected their mental and physical health. Nor were the problems contained to a single store, according to two former pharmacists, who worked in multiple locations across the state and heard similar concerns from other staff members.
“The sheer number of people who go home and cry because of the pressures they’re under — it’s unbelievable,” said Michelle Harmon, a former CVS pharmacist in the Hampton Roads region who’s still part of a Facebook group for mothers in the industry. “You’re so mentally drained you don’t have time for your family. I was just existing — going to work, coming home, doing whatever I could to hit the numbers so my patients were taken care of.”
Safety and staffing issues at national pharmacy chains have become a growing issue for state regulators both in Virginia and across the country. A 2020 investigation by The New York Times found that at least two dozen states have received multiple complaints from pharmacists and physicians worried that chain pharmacy policies are undercutting patient care.
In many cases, the errors have had significant consequences. An 85-year-old in Florida died after a Publix pharmacy dispensed a chemotherapy drug instead of the antidepressant she was prescribed. At the CVS in Virginia Beach, a state inspector reviewed 200 hardcopy prescriptions and found 74 mistakes — an error rate of roughly 37 percent. In at least two cases, pharmacists dispensed medications at multiple times over the prescribed dosage, including cyclobenzaprine, a muscle relaxant, and dexamethasone, an anti-inflammatory drug that’s been used to treat COVID-19 patients.
“Now, in my 32 years of practice in retail pharmacy, this is a classic symptom of going too fast, too distracted, to pay attention to what you’re doing,” Ratliff said during the hearing. At one point, he described the working conditions as “unacceptable,” but the board’s secretive disciplinary process makes it difficult to determine how widespread the problems are across Virginia.
Diane Powers, director of communications for the Virginia Department of Health Professions, said that board investigations are complaint-driven. However, complaints against pharmacies are considered confidential under Virginia state code, she said, making it impossible to know whether other CVS stores have experienced the same problems.
The board did release its final order in the case, but refused to provide the Mercury with a copy of the full investigative report, which was referred to repeatedly during the public hearing. Powers also said the report was exempt from disclosure under the state’s Freedom of Information Act laws.
“Investigations are confidential under law and therefore, the board can neither confirm or deny the existence of any ongoing investigations,” she added in a follow-up statement. Nearly half of the board’s disciplinary case decisions involving pharmacies over the last 90 days have been issued in response to violations by large chain locations, including CVS, Walgreens and Rite Aid. But it’s unclear if any involved complaints similar to those filed against the CVS store in Virginia Beach.
Both Harmon and another former CVS pharmacist, who requested anonymity because she feared professional repercussions, say understaffing has been a growing problem at CVS for years. It only became worse with the arrival of COVID-19, they said.
Before the pandemic, the company had steadily been reducing the number of hours that pharmacy techs, a non-salaried position, were allowed to work every week. The former pharmacist said it was clear some stores didn’t have enough staff to meet the demands of the job, but that the stress was “manageable” until cases of the virus began to spread.
“Then COVID just made things impossible,” she said. “That tipped it over the edge.” Both pharmacists worked at high-volume stores, where they’d fill anywhere between 500 and 1,000 prescriptions a day. Harmon said her pharmacy sometimes received up to 10 phone calls at a time, which employees were expected to answer by the second ring. The pharmacies also ran drive-throughs and provided in-store services, including flu vaccines and counseling patients on their medications.
When COVID-19 hit, the pharmacies also started offering testing and — eventually — vaccinations. The former pharmacist who requested anonymity said CVS sent in additional pharmacists to administer the vaccines, but billing for the shots and registering them in the state’s immunization system fell to the regular staff.
“Before the clinic started, you’d just get pages and pages and pages,” she said. “All of that paperwork went through your pharmacy that’s filling 900 prescriptions a day.” Harmon left the company later, in July of this year, after a brain hemorrhage she said doctors attributed to stress.
“I have fully recovered and I’m thankful for that,” she said. “But as I lay in that bed, I thought to myself, ‘I’ve got to get out of this environment.’”
They aren’t the only CVS employees to report health issues traced to stressful working conditions. According to the Board of Pharmacy decision, a pharmacist at the Virginia Beach location was diagnosed with anxiety and took a medical leave of absence from the store. A technician also took stress-induced leave, and another was prescribed anti-anxiety medication “because of the stress of working” at the pharmacy.
DeAngelis, the spokesman for CVS, described many of the complaints in the report as “inaccurate or outdated” (“It should be noted that the underlying complaints from a former employee are nearly two years old and this store location has since had a change in management,” he wrote in an emailed statement).
Harmon, though, said she had experienced many of the same challenges described in the hearing as recently as July. One of the main stressors, for both her and employees at the Virginia Beach location, were the metrics that CVS set for its stores. According to Harmon, expectations were broken down into a 100-point system, from how fast it took to type a prescription into the system to how quickly it was checked by a pharmacist and delivered to a patient.
But as the company cut down technician hours, Harmon and the other pharmacist said those metrics became harder and harder to meet. With the drive-through and COVID-19 testing to run, they said there was sometimes a single pharmacist and technician left to fill hundreds of prescriptions by themselves. On some days, Harmon said it amounted to filling a prescription every minute and a half in an average 13-hour shift.
There was also what pharmacy board members described in the hearing as “busywork” — other tasks that employees were assigned and rated on. The other former pharmacist said the company expected pharmacists or technicians to call at least 100 patients a week to check if they needed a prescription refilled or wanted to switch to a larger, 90-day supply.
At first, she said CVS budgeted additional staff hours for the calls, but they eventually became part of the daily workload. Harmon said patients were also given the option to request drug delivery instead of picking up the medication in-person.
But the company expected deliveries to go out at a certain time every day, and allowed customers to order additional items from other sections of the store.
“So, I’m having to have a technician stop what she’s doing, filling prescriptions, to go package a non-prescription order,” Harmon said. At some points during the pandemic, she estimated her store received at least 20 orders a day.
Employees said the constant distractions made it impossible to meet metrics and fill prescriptions safely. At one point, one of the pharmacists worked in a store with a backlog of more than 700 orders, when that happened, they said it was up to the salaried pharmacists to work extra hours — or come in over the weekend — to get the store caught up.
The former pharmacists said the workloads made it nearly impossible for pharmacists or technicians to take a break during the day.
At the Virginia Beach location, the Board of Pharmacy found one employee was asked to sign a waiver attesting she wouldn’t take a meal break. Another “routinely” ate her lunch behind the pharmacy safe, according to the board’s order, because the store was too busy to stop working. The former pharmacist who asked for anonymity told the Mercury her pharmacy wasn’t allowed to close for lunch, and there were regularly days when she didn’t have time to use the restroom for an entire 13-hour shift.
DeAngelis noted that management had changed at the Virginia Beach location since the investigation. “In fact, our store’s lead pharmacist and its district leader both appeared at the board hearing to refute the allegations,” he wrote. New district leader Paul McCormick told the board that CVS was in the process of unrolling regularly scheduled lunch breaks at pharmacies nationwide, and that the company had reduced both the number of calls and metrics it expected employees to make and meet.
Board members, though, appeared skeptical that the personnel changes had led to a significant shift in culture. And both former pharmacists said many CVS employees weren’t waiting on improvements, with staff leaving for other jobs.
“Nobody wants to make mistakes,” Harmon added. “That’s why we didn’t take breaks. That’s why we didn’t go to the bathroom. That’s why you come in early and stay late. You basically sacrifice yourself to make sure your patients are taken care of.”
Kate Masters is a reporter for the Virginia Mercury which first published this report.