Fluoride Action Network

Chatham CVS drugstore error leads to oversight agreement

Source: Chatham Courier News | February 25th, 2013
Industry type: Pharmaceuticals

CHATHAM –  A national pharmaceutical retailer has agreed to better oversight procedures and a $650,000 contribution to the state’s prescription drug awareness program following a 2012 incident in which several New Jersey outlets, including one in Chatham, mistakenly mixed a cancer drug in with children’s flouride [sic] medication.

The agreement was announced Monday by State Attorney General Jeffery S. Chiesa and the state’s Division of Consumer Affairs.

In a statement announcing the agreement, Chiesa said the Division began investigating CVS-Caremark in response to an incident that took place between December 2011 and January 2012 at the CVS  pharmacy, located at 471 Main St.

At that time, parents on 15 separate occasions went to the pharmacy with pill bottles containing not only the prescribed  fluoride tablets but also included tablets of tamoxifen, a breast cancer treatment drug, according to the statement.

A subsequent investigation revealed commingling had also  occurred in pharmacies in Budd Lake, Cherry Hill, Rahway, and Scotch Plains.

As a result of the investigation, the Woonsocket, R.I.-based company agreed to several measures, including retraining staff members, and enhancing oversight and quality assurance at its New Jersey pharmacies.

In a separate statement, CVS said the agreement “Acknowledges our continued commitment to enforcing our enhanced procedures.

“At the time of the incidents in question, we conducted a full investigation and determined they occurred due to human error and deviation into some prescriptions that were dispensed to patients with incorrect medication.

“CVS has comprehensive policies in place to ensure prescription safety and errors are a very rare occurrence.”

The pills are similar in size, shape, and color, but can be distinguished by their imprint codes. Flouride tablets are stamped “SCI” on one side and “1007” on the other. Tamoxifen pills have “M” on one side and “274” on the other.


According to the agreement, the company to various terms involving retraining, processes, and public awareness.

As far as retraining and processes are concerned, the company:

•   Has retrained the staff at all of its New Jersey pharmacies in procedures to be followed when unclaimed prescriptions are returned to pharmacy stock. Some of the errors arose when employees overlooked or circumvented the company’s longstanding procedures.

•   Retrained all specialists assigned to stock and dispense medications from automated filling machines. CVS stopped use of the automated filling machines in its New Jersey locations until staff responsible for filling the machines had been retrained.

•   Established enhanced procedures regarding the use of automated filling machines. A pharmacist will visually inspect every pill before loading the machines. Routing refilling of all machines will be scheduled to occur only during specific “down time,” enabling this critical function to take place during less-pressured business hours.

•   Will continue to adhere to its various policies intended to ensure accurate and safe dispensing. Pharmacy supervisors will advise CVS employees throughout New Jersey that noncompliance with company policy and procedure will result in employment consequences proportionate to the conduct.


According to the agreement, in the areas of inspection and oversight, the company agreed to the following:

•   The pharmacist-in-charge at each New Jersey CVS pharmacy will conduct quality assurance reviews at least once every month, with a particular focus on medication safeguards.

•   District supervisors will conduct store visits at least once every month. They will look for any indicators that CVS procedures need reinforcement or that specific individuals need retraining.

•   CVS will notify the Division of Consumer Affairs and State Board of Pharmacy within three days after CVS’s quality assurance department learns that a commingling error has occurred. Within 10 days of learning about an incident, CVS will provide the Division and the Board of Pharmacy with a full report that will include a summary of its investigation and an assessment of the source of the error.

Public Awareness

In addition, CVS will provide consumers with several ways to check the accuracy of medication.

According to the agreement:

•   CVS will use its website to make pill images and clinical information about medications available to the public. Each CVS customer will also be able to view a personalized prescription profile online, with color images of medications and clinical information. This will give the public and additional resource to check the accuracy of medication.

•   The company will also provide posters and single-page pamphlets or similar notices to its New Jersey pharmacies, reminding patients to compare the written description on their prescription labels to the actual contents of the prescription vitals.

•   Finally, CVS will pay $650,000 to the Division to fund a public awareness campaign about the dangers of prescription drug abuse, as well as various concerns associated with the proper use of prescription rugs. The payment will also reimburse the Division for attorneys’ fees and investigative costs incurred during its inquiry into CVS’s activities.

Monitoring Program

According to the agreement, CVS also now provides its New Jersey pharmacists with direct computer access to the New Jersey Prescription Monitoring Program, a Division database that tracks prescriptions for Controlled Dangerous Substances and Human Growth Hormone prescriptions throughout the state.

According to the agreement, the data is provided to registered prescribers and pharmacists and is made available to law enforcement to help root out the illegal diversion and abuse of prescription drugs.