Iowa Board of Pharmacy: Error at Newton Hy-Vee led to overdose, possible death (2024)

Clark Kauffman| Iowa Capital Dispatch

Several Iowa pharmacies have been cited by the state recently for dispensing incorrect medications, including one that may have resulted in a patient's death.

The Iowa Board of Pharmacy alleges that on Jan. 14, the Hy-Vee Pharmacy located at 1501 First Ave. E. in Newton mistakenly dispensed 30 milliliters of morphine concentrate to a patient with incorrect directions on the label, which the board says resulted “in a substantial overdose and possibly early death.” No other information on the case has been made public by the board.

The board has imposed a $5,000 civil penalty against the pharmacy and ordered that the entire professional staff at the pharmacy undergo training on medication errors and patient safety.

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Other cases recently addressed by the board include:

Hy-Vee Pharmacy, 2827 Hamilton Blvd., Sioux City

The board alleged that on Oct. 6, 2023, the pharmacy incorrectly administered an influenza vaccine to a patient who had requested a COVID-19 booster vaccination. The board imposed a $2,000 civil penalty, and the entire professional staff was ordered to undergo training on medication errors and patient safety.

Hy-Vee Pharmacy, 351 N.E. Gateway Drive, Grimes

The board charged the pharmacy with dispensing an incorrect prescription to a patient on May 29, 2023. No other information on the incident was disclosed by the board. The board imposed a $2,500 civil penalty and the entire professional staff was ordered to undergo training on medication errors and patient safety.

CVS Pharmacy, 14201 Hickman Road, Urbandale

The board alleged the pharmacy failed to provide the correct amount of medication to a patient who is a minor. When the minor’s caregiver later requested a refill, the pharmacy ― unaware it had initially provided the wrong amount of medication ― informed the caregiver no refill or “hold over” medication was available. The patient later suffered a seizure as a result.

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While the publicly available board records are unclear as to the chronology of events, it appears the board also alleged the pharmacy made additional, subsequent errors with the same patient ― first by filling a prescription for 52 tablets of medication with only 51 tablets, and then by shorting the patient 100 tablets of an unspecified medication. The board imposed a $5,000 civil penalty on the store.

Monroe Community Pharmacy,112 E. Washington St., Monroe

The board charged the pharmacy with failing to reconcile its actual inventory of narcotics with its documented supply, maintain complete and accurate pharmacy records, have adequate policies in place with regard to narcotics, and train pharmacy technicians at a telepharmacy site.

According to the board, the pharmacy determined controlled substances were missing from its inventory in October 2023. An investigation revealed that an employee had stolen more than 700 Adderall tablets and capsules of various dosages over the previous eight months, and that the pharmacy had no policies in place regarding the physical inspection of and reconciliation for its inventory of controlled substances.

The board fined the pharmacy $3,500 and placed its license on probation for three years. In addition, the board ordered that the pharmacy staff complete educational training on narcotic theft.

In a separate but related case, the board charged Douglas Niedermann, the Iowa-licensed pharmacist in charge at the Monroe pharmacy, with failing to audit and reconcile the inventory and maintain complete and accurate pharmacy records. The board imposed a $500 civil penalty on Niedermann for the violations and ordered him to complete complete-education courses on controlled substances and theft of narcotics.

CVS Pharmacy, Ankeny or Altoona

The board’s published decision indicates the case involved a CVS Pharmacy located somewhere in Ankeny, but the same records indicate the relevant store is located at 3414 EighthSt. S.W. in Altoona. The board charged the store with failing to complete Drug Enforcement Agency records as to the loss of controlled substances, committing an act that would render its Controlled Substances Act registration “inconsistent with the public interest,” and failing to submit a form to the DEA within 14 days of the theft or loss of controlled substances.

The publicly available board documents give no indication of what drugs were lost, how they were lost, or the quantity of drugs lost. The board imposed a civil penalty of $5,000 and placed the business’ pharmacy license and its Controlled Substances Act registration on probation for two years.

DCA Pharmacy, Franklin, Tennessee

From January 2022 to January 2024, DCA Pharmacy allegedly filled 2,655 prescriptions for Iowa customers, all without the required license. The action was apparently uncovered only when DCA applied for a new Iowa license in January of this year.

In addition, the board also accused DCA of shipping compounded progesterone capsules to Iowa, despite its inability to show any of the required evidence of a clinically significant difference between the compounded medication and that which was available otherwise. The board imposed a $5,000 penalty against the company.

As part of a separate but related case, the board fined DCA’s pharmacist in charge, West Conner, $1,000.

Iowa Board of Pharmacy: Error at Newton Hy-Vee led to overdose, possible death (2024)
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