CVS mix-up of tamoxifen, fluoride tablets affects 13 prescriptions

March 7, 2012

Between Dec. 20, 2011, and January and Feb. 20, 2012, a CVS pharmacy in Chatham, N.J., dispensed tamoxifen tablets instead of 0.5 mg chewable fluoride pills. The mix-up could have affected as many as 50 children, but only 13 prescriptions were found to definitely be affected, according to a CVS statement.

Between Dec. 20, 2011, and January and Feb. 20, 2012, a CVS pharmacy in Chatham, N.J., dispensed tamoxifen tablets instead of 0.5 mg chewable fluoride pills. The mix-up could have affected as many as 50 children, but only 13 prescriptions definitely were found to be affected, according to a CVS statement.

Michael J. DeAngelis, a spokesperson for CVS, stated that all families that could have received the wrong medication were contacted as soon as the mix-up was uncovered. "Fortunately, most of the families we spoke to informed us that their children did not receive any incorrect pills," he stated. "We will continue to follow up with families who believe that their children may have received incorrect medication. Thankfully, no negative effects have been reported."

DeAngelis said that the incident involved only a few tamoxifen pills mixed in with the fluoride tablets and that it was due to a "single medication restocking issue" at the Chatham pharmacy. The problem was brought to the pharmacy's attention by a parent, according to DeAngelis.

Even though the 2 medications are both white, round, and the same size, no one should identify a medication based on appearance alone, said Michael R. Cohen, RPh, president of the Institute for Safe Medication Practices in Horsham, Pa. Bottles of medications have barcodes that identify the contents, he noted.

Cohen speculated that either a prescription of tamoxifen was never picked up and the pills were then mistakenly put into a bottle of fluoride tablets or that a large bottle of tamoxifen with a few left was emptied into a bottle of fluoride tablets to clear the shelf. Another possibility is that a cassette in an automated dispensing machine was filled with the wrong medication, he added. In any event, the container barcodes should have been scanned to ensure that the right pills were going into the right container, he said.

"This is just crazy. Where is the supervision? Where is the management oversight?" Cohen asked. "I don't see this as a CVS problem. I see the same types of errors again and again. The focus on safety is not No. 1."

The consumer affairs division of New Jersey's attorney general's office has called for CVS to provide information on how the switch occurred, along with all communications about the problem. Company representatives will have to appear for questioning. CVS is conducting its own investigation. "We are also cooperating fully with the New Jersey attorney general’s office," CVS's DeAngelis said.