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CVS Admits Commingling Prescriptions at Scotch Plains Store

Pharmacy agreed to retrain all staff on pharmacy procedures and to pay $650,000 to the state for a public awareness campaign about the proper use of prescription drugs.


The state Division of Consumer Affairs and CVS-Caremark reached an agreement addressing the commingling of prescription drugs at five New Jersey locations in 2012.

A total of 15 parents who filled their children's chewable fluoride prescriptions in December 2011 and January 2012 at the CVS Pharmacy on Main Street in Chatham Borough reported noting tablets in the bottles that were not like the others. The strange pills turned out to be the breast cancer drug tamoxifen.

Both pills are white, round and about the same size. Tamoxifen pills have the letter "M" stamped on one side and "274" on the other. Fluoride pills have the letters "SCI" on one side and the numbers "1007" on the other.

Attorney General Jeffrey S. Chiesa and the DCA said after the commingled prescriptions in Chatham went public, CVS came forward when customers in four other New Jersey towns received pill bottles with the wrong medications:

  • Three customers at a CVS in Cherry Hill received bottles which commingled metoprolol, a high blood pressure drug, with the schizophrenia drug risperidone on or about March 3, 2012.
  • One customer at a CVS in Budd Lake was given pravastatin, a cholesterol drug, instead of metformin, a diabetes medication. This customer was concerned she consumed the wrong medication and visited an emergency room on or about March 7.
  • A CVS in Rahway filled a prescription calling for 80 mg. tablets of Coreg, a blood pressure drug, at 20 milligrams per tablet on or about March 11. No patients are known to have taken the wrong dosage.
  • A CVS in Scotch Plains dispensed about 30 prescriptions from an automated filling machine in which pills for atorvastatin, a cholesterol drug, were accidentally commingled with pills for losartan, a blood pressure drug. There is no indication that patients took the wrong medication.

CVS reached out to all potentially affected consumers and notified the DCA and the State Board of Pharmacy.

The DCA launched an inquiry into CVS and ordered them to produce extensive documentation of these instances. Corporate representatives were ordered to appear in person at DCA headquarters in Newark and answer questions under oath about the Chatham CVS operations and other incidents of commingled prescriptions.

Some of these errors took place "when employees overlooked or circumvented the company's longstanding procedures" on returning unclaimed prescriptions to pharmacy stock, according to a press statement from the DCA.

"For example, when returning unclaimed prescriptions back to store inventory, employees may have poured the pills into the wrong stock bottles even though CVS policy dictated that unclaimed prescriptions should not be returned to stock bottles at all," the statement reads.

Other errors took place when staff loaded the bins for the automated filling machines with pills that had been improperly mixed, according to the statement.

Eric T. Kanefsky, the acting director of the DCA, said CVS agreed to "a significant payment" to help further public education about prescription drug safety. "The prescriptions that pharmacies dispense include Controlled Dangerous Substances (CDSs). The fight against the abuse and diversion of dangerous medications, including CDS, has been a priority of the Division in recent years."

CVS-Caremark agreed to pay $650,000 to the DCA for a public awareness campaign about the dangers of prescription drug abuse. This payment will also reimburse the DCA for attorneys’ fees and investigative costs incurred during its inquiry into CVS.

CVS developed enhanced procedures for the automated filling machines, and stopped use of the machines until after all specialists could be retrained.

Head pharmacists will have to do a monthly quality assurance review, and district supervisors will conduct store visits once a month to ensure procedures are being followed.

CVS also put in access to the New Jersey Prescription Monitoring Program in every New Jersey pharmacy. This database is maintained by the DCA and tracks prescription drugs for their potential illegal diversion and abuse.

If any future instances of commingling come up, CVS must notify the DCA within three days and provide a full report, including a summary of the investigation and an assessment of the source of the error, within 10 days.

CVS also agreed  to put color images and clinical information of medication on their website, so customers can view their personalized prescription profile online to see what their medications should look like. Customers will also receive notices to check their medication with the written description on the bottle

Neal Buccino of the DCA said CVS "was very cooperative and informed us of these matters as they came up," and continued to cooperate with the DCA throughout their inquiry.

"This was the best way to resolve this in a way to make sure the public safety was addressed," Buccino said.

mtevc February 26, 2013 at 07:12 PM
I received 2 wrong medications from them. I also got a call from corporate saying I needed to return one medication for replacement. Seems they had stored the medicine incorrectly, which might have impacted effectiveness. Not going to get medicine there anymore.
C February 26, 2013 at 07:23 PM
I find this to be a bigger story then GPS taken from open cars but your the first to comment. I find it silly.
Nicole Bitette (Editor) February 26, 2013 at 07:43 PM
Hi mtevc, Thanks for commenting on your experience with them. Sorry to hear about this!
C is off the meds February 26, 2013 at 08:15 PM
Based on his other rants, I think that C may have also had his meds stored at the incorrect temperature.
C February 26, 2013 at 09:08 PM
Based by the lack of other comments, i believe you may be someone else who just created a new account to post this. And based on that fact i believe your are DB. Just my observation.
mm February 27, 2013 at 06:05 AM
and this is why I get all my prescriptions filled from Quick Chek pharmacy on Westfield ... the druggists and the staff there are great!
douglassgrad February 27, 2013 at 01:17 PM
I left CVS many years ago when they gave me the wrong prescription for one of my children -- it was just the wrong form of prescription vitamins, tablets rather than the liquid the doctor had specified -- but I thought if they'd made that mistake, what other mistakes were they making. Combine that with the terrible service (calling ahead to see if a prescription was ready and then having to wait 20 minutes when I arrived) and that was it. I too go to the Quick Chek pharmacy on Westfield Ave. The staff is wonderful -- they go out of their way to help with your insurance, offer recommendations for otc medicine and get you in and out quickly if you come in to have prescriptions filled when you are sick.
CAMERON J HALL February 28, 2013 at 04:19 PM
Every time I go to CVS they have been understaffed. The same person at the register is also filling prescriptions. This is always a recipe for mistakes as this causes a lack of focus on where they left off filling orders. Hire more people to enable better focusing. The last time I was there the same person was running around accepting prescriptions, answering the phone, working the drive-in, filling orders and working the register. What should have taken 5 minutes to process my pickup turned into almost three times as long because of this. No wonder these mistakes are happening!
Teresa Heath February 28, 2013 at 09:44 PM
Its not just about focusing. I worked for several years as a tech and heard horror stories from the Pharmacists that have worked for the CVS stores, and they don't even get breaks durning 12 hour shifts... Pharmacists make decent money, but have too high of expectations for a serious job. They need breaks, at least 1 half hour break and two 15 min breaks. There should be more then 1 pharmacist on at a time.

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