Pharmacists with the nation\u2019s largest retail pharmacy chain felt dangerously burned out.<\/p>\n\n\n\n
It was August 2020. The pandemic was in full swing, straining an already weary workforce hit by a decade of relentless budget cuts and rising demands.<\/p>\n\n\n\n
One by one, the pharmacists dialed into a weekly conference call with their boss. He could have empathized with them or addressed the reality of their pressure-cooker environment \u2013 one that breeds medication errors and creates missed opportunities to prevent potentially deadly mistakes.<\/p>\n\n\n\n
Instead, CVS District Leader Khalil Haidar turned up the heat. He harped on his Texas-and-Louisiana-based team to hit corporate quotas: Sell more store memberships. Push for more prescription pickups. Vaccinate more people. He threatened discipline and staff cuts unless pharmacists convinced at least five customers that week to get a flu shot before flu season had even officially started.<\/p>\n\n\n\n
\u201cIf you get your goal, nobody will come after you,” Haidar said on the call, one of several recorded and shared with USA TODAY. “And many patients, they are ignorant. They don\u2019t know what the flu is … How are you going to convince them? How can you persuade them? That\u2019s your job as a pharmacist.\u201d<\/p>\n\n\n\n
Pharmacists take an oath to hold patient safety in the highest regard when preparing and dispensing medication. But rising pressures inside the nation\u2019s largest retail chains have forced pharmacists to choose between that oath and their job.<\/p>\n\n\n\n
The situation was bad before the pandemic. COVID-19 made it worse. It has only gone downhill since then. Frustrations boiled over this autumn in a series of high-profile walkouts<\/u><\/a> that left a string of CVS and Walgreens pharmacies shuttered or short-staffed<\/u><\/a>. Those actions might have caught consumers off guard. But inside the troubled industry, it was the clarion call of a beleaguered workforce pushed to the brink.<\/p>\n\n\n\n Corporations like CVS, Rite Aid, Walgreens and Walmart have consistently slashed pharmacy staffing levels while simultaneously saddling their frontline workers with a burgeoning list of additional duties.<\/p>\n\n\n\n Stores that a decade ago might have had two pharmacists and six pharmacy technicians filling an average of 500 prescriptions a day now may have half the staff and an even higher prescription volume \u2013 plus an endless crush of vaccine appointments, rapid tests and patient consultation calls.<\/p>\n\n\n\n Every task is timed and measured against corporate goals that reward speed and profits. Staff who do not fill prescriptions fast enough, answer the phones quickly enough or drum up enough vaccination business can face discipline, reassignment or termination.<\/p>\n\n\n\n Pharmacists said it\u2019s nearly impossible to meet all the demands without cutting corners, and when corners get cut, patients can get hurt.<\/p>\n\n\n\n \u201cThe public\u2019s health is in danger,\u201d said Oklahoma City pharmacist Bled Tanoe, who quit her job at Walgreens in August 2021 over what she considered unsafe staffing levels and an emphasis on hitting corporate targets. \u201cThe incidents of error are multiplied by infinity.\u201d<\/p>\n\n\n\n USA TODAY interviewed four dozen current and former retail pharmacists from different chains across the nation and spoke with industry leaders, patient advocates and patients harmed by pharmacy errors. Many pharmacists spoke to USA TODAY on the condition of anonymity to protect their jobs.<\/p>\n\n\n\n The media organization also reviewed more than 100 emails from chain pharmacists sharing their concerns; inspected internal emails, text messages, metric score sheets and coaching notes; and listened to more than five hours of recorded conference calls.<\/p>\n\n\n\n These interviews, audio recordings and documents \u2013 along with dozens of pharmacist workplace surveys, task force studies and state board of pharmacy reports \u2013 add up to a prescription for disaster.<\/p>\n\n\n\n \u201cI could cry as to what\u2019s happening in my profession,\u201d said Daniel A. Hussar, a professor and dean emeritus at the Philadelphia College of Pharmacy, where he taught for 52 years before retiring in 2018 to focus on his family and his blog, The Pharmacist Activist.<\/p>\n\n\n\n Hussar lamented the transformation of a once-vaunted career into the equivalent of a fast-food job whose workers are pressured to upsell every customer and race through every order. Mistakes in that environment are not only common, he said, they\u2019re potentially fatal.<\/p>\n\n\n\n \u201cAt corporations like CVS, Walgreens, Walmart, Rite Aid \u2013 the huge pharmacies \u2013 errors are a cost of doing business,\u201d Hussar said. \u201cI don\u2019t think the boards of pharmacy or the colleges of pharmacy or the professional associations are doing enough to address the issues.\u201d<\/p>\n\n\n\n For years, pharmacists have reported these problems to their state boards, complained to their professional organizations and warned the media. The New York Times wrote about how the dangerous workload imperils patient safety<\/u><\/a> just before the pandemic hit U.S. shores.<\/p>\n\n\n\n Promises were made and broken \u2013 documented by pharmacists themselves in state surveys that followed.<\/p>\n\n\n\n In California<\/u><\/a>, 91% of chain pharmacists surveyed by the state Board of Pharmacy in 2021 said they lacked the staff needed to ensure adequate patient care. More than half of pharmacists polled by the Kansas Board of Pharmacy<\/u><\/a> in 2022 said they didn\u2019t feel they could perform their jobs safely; the biggest reasons cited were a lack of adequate staffing and employer-imposed metrics, like filling a specific number of prescriptions a day or providing service to customers within a set time.<\/p>\n\n\n\n Hundreds of pharmacists in Ohio<\/u><\/a> responded to a 2020 callout from their state board about the toll of their workload on patient safety in a report made public in the next year.<\/p>\n\n\n\n \u201cI feel a mistake is breathing down my neck as I try to manage all the tasks that I am asked to perform,\u201d one wrote. Another said they had left the profession because \u201cthe environment was set up for me to fail.\u201d<\/p>\n\n\n\n State regulatory bodies overseeing pharmacies have for years refused to intervene. Their role is mainly to protect consumers, not pharmacists, and they traditionally considered many of these complaints \u2013 staffing, metrics, workload \u2013 outside their purview. They were seen as business decisions, not consumer safety issues, said Karen Winslow, interim executive director of the Virginia Pharmacy Association.<\/p>\n\n\n\n That\u2019s starting to change, but not without a fight.<\/p>\n\n\n\n Ohio proposed a series of rules this year aimed at improving pharmacy working conditions. Among them: A ban on quotas and requirements for sufficient staffing. The rules are currently pending a vote amid overwhelming support from pharmacists and opposition from retail pharmacy chains, including Walgreens and CVS.<\/p>\n\n\n\n \u201cThe Board should stay focused on the regulation of the practice of pharmacy rather than the business of pharmacy,\u201d wrote CVS Director of Regulatory Affairs John Long in opposing an early version of Ohio\u2019s rules last year.<\/p>\n\n\n\n Virginia passed emergency regulations in late September also banning production quotas and bolstering pharmacy staffing. Those rules are in effect until March 2025, giving the state time to develop and pass more permanent measures.<\/p>\n\n\n\n Enforcing these rules could prove challenging. California, one of the first states to outlaw pharmacy production quotas and mandate minimum staffing, is coping with routine violations by retail pharmacies that then fail to provide records to inspectors seeking to verify complaints, state Board of Pharmacy minutes show.<\/p>\n\n\n\n Professional associations, meanwhile, have earned their members\u2019 scorn for hosting workshops on resiliency rather than advocating for better working conditions. Many pharmacists told USA TODAY they feel like no one stands up for them.<\/p>\n\n\n\n That, too, is starting to change. In the wake of the CVS walkouts last month, the new head of the American Pharmacists Association, the industry\u2019s largest professional organization, flew to Kansas City to meet with the organizers and committed to more aggressive leadership on these issues.<\/p>\n\n\n\n \u201cThe APhA has been focused on longer-term fixes, and what we\u2019ve heard loud and clear is we need to focus on the acute problems,\u201d said Michael Hogue, the association\u2019s chief executive officer and executive vice president. \u201cThat\u2019s what we\u2019re going to do.\u201d<\/p>\n\n\n\n USA TODAY reached out to CVS, Walgreens, Walmart and Rite Aid for comment.<\/p>\n\n\n\n Representatives of CVS and Walgreens generally acknowledged the challenges their pharmacists have faced in recent years but denied allegations of dangerous working conditions. They said goal-based metrics on measurable objectives such as quick prescription turnarounds, short telephone hold times and vaccination volumes are standard within the industry and meant to assess quality rather than penalize staff.<\/p>\n\n\n\n CVS, Rite Aid, Walgreens and Walmart all emphasized their commitments to patient safety and described their various efforts to continually reduce error rates.<\/p>\n\n\n\n \u201cPatient safety is our highest priority,\u201d Amy Thibault, CVS Pharmacy\u2019s lead director of external communications, told USA TODAY. \u201cOur more than 30,000 CVS pharmacists approach this responsibility with seriousness and dedication and we work hard to earn the trust of our pharmacy patients.\u201d<\/p>\n\n\n\n CVS, Walgreens and Walmart also said they have invested in new technologies to streamline services, increased wages to better recruit and retain staff, and rolled out new initiatives to support their teams and reduce their workloads.<\/p>\n\n\n\n The major chains now provide half-hour lunch breaks for staff. Many also recently announced reduced pharmacy hours at locations nationwide. Walmart spokesman Tyler Thomason said reduced operating hours promote a \u201cbetter work\/life balance.\u201d<\/p>\n\n\n\n But pharmacists told USA TODAY their workloads remain the same and that they\u2019re pressured to work through lunch and stay late to finish everything. At locations where hours were cut, many pharmacists said, they\u2019ve seen their salaries decrease accordingly.<\/p>\n\n\n\n \u201cI\u2019ve given the company thousands and thousands of dollars in free labor,\u201d said a CVS pharmacist who was on Haidar\u2019s team during the pandemic-era conference calls. \u201cOur bosses can log into the computer any time and tell how far behind we are. They will send group texts and say, \u2018I see you\u2019re trending behind. What are your plans to finish it tonight?\u2019 Very intimidating comments. You fear for your job all the time.\u201d<\/p>\n\n\n\n Haidar, who now leads a different team, told USA TODAY the recordings must have been altered and that he never threatened staff with discipline for falling short of vaccination goals. He also said they are not an accurate depiction of his leadership. When asked if he would like to listen to the recordings, Haidar declined.<\/p>\n\n\n\n Michael DeAngelis, CVS\u2019 executive director of corporate communications, said it is not the company\u2019s \u201cpolicy or practice to penalize pharmacy teams regarding the number of vaccinations they administer\u201d and that it \u201cis committed to compensating our colleagues appropriately for the hours they work.\u201d<\/p>\n\n\n\n DeAngelis also said CVS recently reduced its pharmacy metrics by 50%, but he declined to provide additional details.<\/p>\n\n\n\n Walgreens announced last year the complete elimination of performance-based metrics, the only major chain to have taken such a step. But interviews with pharmacists and documents provided to USA TODAY show the company continues to push staff to hit unrealistic goals.<\/p>\n\n\n\n One Walgreens pharmacist said she was reprimanded earlier this month for taking too long to verify prescriptions, even though her extra diligence had caught several serious mistakes.<\/p>\n\n\n\n According to notes from her coaching session, shared with USA TODAY, she should take less than 30 seconds to verify the accuracy and appropriateness of every prescription, in addition to checking for potential problems like drug allergies or interactions.<\/p>\n\n\n\n \u201cI pray every day that I don\u2019t miss something or cause a patient harm,\u201d said the Tennessee-based pharmacist, who estimates she handles several hundred prescriptions daily. \u201cI feel guilty knowing that I would want someone to double check the math on a prescription of antibiotics for my child, but I don\u2019t have time to do that for their child.\u201d<\/p>\n\n\n\n Medication errors are a pharmacist\u2019s worst nightmare. Many told USA TODAY they lie awake at night wondering if, in their haste, they made a mistake that might hurt or kill someone.<\/p>\n\n\n\n In May 2021, that someone was Brenden Fisher.<\/p>\n\n\n\n The Sarasota, Florida, child overdosed on a newly prescribed anti-seizure medication after the CVS pharmacy near his home dispensed the drug with the wrong instructions on the label.<\/p>\n\n\n\n By the third dose, Brenden was lethargic, dazed and struggling to breathe. His parents, Paris Bean and Jason Fisher, rushed their then-2-year-old to the hospital, thinking he was dying.<\/p>\n\n\n\n Hospital staff didn\u2019t know what was wrong with him, Bean recalled, until a nurse asked if he was taking his 1.2 ml of levetiracetam twice daily.<\/p>\n\n\n\n When Bean told her the instructions said to give him 7.5 ml, \u201cyou could almost hear her jaw drop,\u201d Bean recalled. \u201cShe said, \u2018Did you give that to him?\u2019 And I said, \u2018Yes. Is that why we\u2019re here?\u2019 She said, \u2018I wouldn\u2019t be surprised.\u2019\u201d<\/p>\n\n\n\n Brenden still suffers from a full-body tic he first developed during the incident, his parents said. Dozens of times a day, he will suddenly stop whatever he is doing, clasp his hands together, clench his jaw and tense every muscle in his body while staring off into space. Each episode lasts anywhere from 5-10 seconds.<\/p>\n\n\n\n His parents haven\u2019t been able to definitively link the tic to the overdose, but they said they have no other explanation for it.<\/p>\n\n\n\n Anti-seizure medications like levetiracetam depress the central nervous system, Hussar said. Because nerves tell muscles when to contract and relax, he said, there could be a connection between the overdose and Brenden\u2019s involuntary muscle contractions.<\/p>\n\n\n\n Bean said she blames CVS for the mistake but also herself: \u201cI\u2019m the one who physically administered it … I could have killed him.\u201d<\/p>\n\n\n\n CVS declined to comment on the error.<\/p>\n\n\n\n Bean and her husband filed a lawsuit against CVS in February that was settled out of court for an undisclosed sum. But they said they did not file a complaint with the Florida Board of Pharmacy.<\/p>\n\n\n\n That means it\u2019s one of countless errors for which there\u2019s no official tally or public record.<\/p>\n\n\n\n Despite a widespread industry belief that medication errors are on the rise as a result of unsafe working conditions, there is no reliable or comprehensive public data to prove it.<\/p>\n\n\n\n No federal agency requires pharmacists to report medication errors, and few state boards of pharmacy mandate it. Many pharmacies and pharmacy chains track errors internally but do not share the numbers with the public. CVS and Walgreens both declined to share their data with USA TODAY.<\/p>\n\n\n\n \u201cThere really is no way of knowing how many errors are actually out there,\u201d said Larry Selkow, a retired California pharmacist who recently served on the American Public Health Association\u2019s task force on pharmacy medication safety issues.<\/p>\n\n\n\n The group estimated U.S. pharmacies annually make 54 million dispensing errors, of which 2.3 million are potentially harmful. It recommended the establishment<\/u><\/a> of a national pharmacy reporting system to collect data on errors and their underlying causes. Having such information, Selkow said, would allow pharmacies to adopt practices to prevent future mistakes.<\/p>\n\n\n\n Numerous pharmacists told USA TODAY that errors are not consistently reported \u2013 even internally. Small mistakes and those caught early are routinely hidden.<\/p>\n\n\n\n \u201cSome pharmacists don\u2019t report it especially if they\u2019ve already had, like, five errors that year,” said Shane Jerominski, a California pharmacist who worked for both Walgreens and CVS. “For every error that gets found out, there will be an error that never gets caught.”<\/p>\n\n\n\n Even when they do report potentially fatal errors, some pharmacists said, no one from their companies investigates how they occurred or makes changes to prevent them from repeating.<\/p>\n\n\n\n A former CVS pharmacy manager at a short-staffed, high-volume store in Georgia said he was horrified when one of his patients who was prescribed Bisoprolol for high blood pressure accidentally received a sleeping aid called Belsomra and got sick after she started taking it.<\/p>\n\n\n\n The pharmacist, who now works for Walmart, said he had hoped the error would be a wake-up call for higher-ups who might finally give his store adequate staffing. It didn\u2019t work out that way.<\/p>\n\n\n\n \u201cThey had me do that little report, but my manager, nobody ever followed up,\u201d he said. \u201cThey were like, \u2018OK, cool, see if she would like a gift card, and we\u2019ll handle it from here.\u2019 And that was it. It\u2019s like they could care less. Like it didn\u2019t even happen.\u201d<\/p>\n\n\n\n CVS did not comment on the incident, but Thibault said that the company\u2019s first priority when it learns of any error is the patient\u2019s safety. She said it then takes steps to correct the error and learn from it. Walgreens said in a statement that it\u2019s mandatory for employees to report errors under the company\u2019s \u201cContinuous Quality Improvement Program.\u201d<\/p>\n\n\n\n \u201cWe take any prescription error very seriously and have a multi-step prescription filling process with numerous safety checks to minimize the rare chance of human error,\u201d said Marty Maloney, Walgreens\u2019 senior manager of media relations.<\/p>\n\n\n\n Pharmacists are personally liable for medication errors and risk fines, discipline and loss of license if investigated and found responsible by their state board. Many told USA TODAY they get little or no support from their company when mistakes happen, even if the conditions imposed by those companies contributed to the error.<\/p>\n\n\n\nMedication errors: A pharmacist’s worst nightmare<\/strong><\/strong><\/h2>\n\n\n\n