Are VA workloads, lack of standards causing pharmacist errors?

An administrative hearing for a fired pharmacist has provided an eye-opening look into the workloads and the lack of accuracy standards for pharmacists working at Veterans Administration (VA) facilities in New Jersey.

The hearing was for Muhamad Sadiq, a pharmacist fired for an error that resulted in a patient receiving more than the ordered dose of medication. Sadiq maintains he was unfairly singled out for discipline and that other VA pharmacists were not disciplined for much more egregious mistakes, including fatal errors.

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According to a story in the Washington Times, what became clear during the hearing are unreasonable workloads for VA pharmacists and the absence of any error rate standards.

One pharmacist testified of having to handle more than 240 orders at a VA nursing home during a single shift in 2011. “It's a dangerous situation there; it should not be allowed to continue," the staff pharmacist reportedly told a supervisor. "Did I make mistakes that day? I hope not."

Other pharmacists testified that colleagues that made serious or fatal errors kept their jobs and were not severely disciplined. According to records obtained by the Washington Times, a pharmacist responsible for 2001 chemotherapy overdose that eventually led to a patient’s death continued work for the VA for years. 

A VA spokeswoman, Sandra Warren, denied that charge. "There have not been any reports of a patient's death from a medication error by a pharmacist at the VA New Jersey Health Care System, including the East Orange or Lyons Campuses or any of the nine Community Based Outpatient Clinics," Warren, told the newspaper. "The patient was treated for the overdose, discharged home several days later, and subsequently died while under hospice care."

An attorney representing Sadiq said the VA is withholding information about dispensing errors that might prove the pharmacist’s contention that he was unfairly singled out. "The point is, a system was never put in place to track errors, eradicate errors, or find out the extent of errors," Ellen Lauderdale, Sadiq’s attorney, said. "Nothing was done as a result of a pharmacist killing a man."

The newspaper report did not specify when Sadiq was fired or when a decision on his appeal is expected. Warren told Drug Topics: “Because of ongoing litigation, we cannot discuss this specific case.”