Number of CA Pharmacy Error Investigations Spiked During COVID

Data obtained by NBC Bay Area’s Investigative Unit show the number of state investigations into pharmacy mistake complaints shot up before and during the COVID crisis

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The California State Board of Pharmacy is currently investigating a large increase in reported pharmacy errors and whether pandemic-related workforce issues played a role in the spike.

Earlier this month, the Investigative Unit first reported on industrywide concerns that pandemic-related pharmacy burnout caused by staffing shortages and added workload is leading to dangerous prescription mistakes.

Data on actual pharmacy mistakes is limited because pharmacies are not required to report mistakes to regulators, so NBC Bay Area’s Investigative Unit filed a public records request for the number of investigations the Board initiated after receiving pharmacy error complaints – some involved serious patient harm and death. The data shows:

  • During fiscal year 2018-19, the California State Board of Pharmacy initiated 138 investigations in response to complaints of pharmacy mistakes harming patients.
  • When COVID hit the next year, the Board started 294 investigations, a 113% increase. Pre-pandemic factors likely contributed to this spike.
  • The next full fiscal year, 2020-21, which was all during the pandemic, that number jumped even higher to 367 investigations.

“[The] Board is deeply concerns about potential negative impacts to patient care,” Bob Davila, a spokesperson for the Board, wrote in a statement to the Investigative Unit. This was in response to a state survey revealing an alarming number of California pharmacists and technicians reporting workplace burnout and prescription errors putting patients at risk.

NBC Bay Area’s Investigative Unit reported that pharmacies across the state, and in the Bay Area, are facing major staffing shortages and employee burnout -- all having an impact on prescriptions. Investigative Reporter Candice Nguyen has some insight.

Susan Bonilla is the CEO of the California Pharmacists Association. She said what was already an overburdened and fragile system had an incredible weight placed on it by the pandemic. She added, concerns are more prevalent at big chain pharmacies. Multiple current and former chain workers told NBC Bay Area they’re pushed to fill a certain number of prescriptions in a specific period of time, unlike independent pharmacy workers.

“The chains are all owned by large corporations. They have stockholders; they are focused on their profits,” said Bonilla. “When you’re talking about an independent pharmacist, who is a small business man or woman running a neighborhood store for their community, they are really there for the patients.”

Big chains like Rite Aid, CVS and Walgreens declined interviews with the Investigative Unit but all said in statements safety is their top priority. CVS said it’s adding workers pointing to a nationwide workforce shortage and Rite Aid said it made temporary changes to store hours companywide so workers could catch up on prescriptions.

The California State Board of Pharmacy also declined an interview saying it established an ad hoc committee to further gather information and come up with possible solutions to reduce errors. The committee’s first meeting was Jan. 27, 2022. Additional meetings are scheduled April 20, 2022; July 13, 2022; and Sep. 14, 2022. At the conclusion of its work, the committee will report its findings and possible recommendations for consideration by the Board of Pharmacy.

What can you do to protect yourself from pharmacy mistakes?

  1. Everyone can and should double check their prescription. Consumer Investigator Chris Chmura explains how to do that.  
  2. If you find an error, report the mistake to the California State Board of Pharmacy by clicking this link.
  3. If you’re able, don’t rush your prescriptions.
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