- The Washington Times - Monday, January 12, 2015

Pharmacists who made serious or potentially fatal errors dispensing drugs at the VA in New Jersey kept their jobs and often weren’t even severely disciplined, according to testimony from their colleagues and other records.

One chemotherapy patient died after a 2001 overdose, but the pharmacist continued working for the VA for years, according to records obtained by The Washington Times under the Freedom of Information Act.

In another case, a pharmacist prescribed a potentially fatal dose of another medication, but neither that employee nor a supervisor, who also had a history of prescribing errors, was disciplined beyond being ordered to undergo counseling.

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The records were filed in an administrative hearing for Muhamad Sadiq, a pharmacist whom the VA fired but who is appealing the decision, saying he was being singled out even though colleagues made even worse errors.

“Errors might be pointed out, but in a global sense, nobody is going to be publicly identified and held out to dry for a mistake,” one staff pharmacist testified in an administrative hearing.

The 2001 chemotherapy case was the most egregious to come to light. According to partly redacted administrative records and transcripts at the Merit Systems Protection Board, he received a dose that was five times the prescribed amount of chemotherapy medication.

A staff pharmacist testified that another pharmacist had erred in reading the milligram strength off of a box of medication.

“Later I came to find out there was a fivefold medication error made, resulting in the death of a patient,” the pharmacist said.

The patient died within weeks, and a root cause analysis showed the death was “hastened by the overdose,” but the pharmacist said that there was no indication of any formal action taken by the VA after the error, according to transcripts.

A decade later, the VA insists the drug error wasn’t to blame for the death.

“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,” said Sandra Warren, a VA spokeswoman.

“The patient was treated for the overdose, discharged home several days later and subsequently died while under hospice care.”

She declined to discuss Mr. Sadiq’s appeal, citing privacy rules, but acknowledged that “there was a pharmacist error resulting in a patient receiving more than the ordered dose of medication for a specific condition.”

A union official representing Mr. Sadiq said records in the case show the error was clearly fatal, and that other serious oversight issues have persisted.

Union officials said they also had trouble getting the VA to turn over information about other prescription errors, which are vital to Mr. Sadiq’s contention that he was held to a different standard than colleagues.

“The point is, a system was never put in place to track errors, eradicate errors or find out the extent of errors,” said Eleanor Lauderdale, an attorney with the American Federation of Government Employees Local 1012, who represents Mr. Sadiq. “Nothing was done as a result of a pharmacist killing a man.”

Indeed, one pharmacist supervisor testified during a Merit Systems Protection Board hearing that there’s no acceptable error rate for VA pharmacists.

Another staff pharmacist testified that management appeared reluctant to hold employees accountable for mistakes.

The same staff pharmacist who testified about the fivefold error in chemotherapy medication also said he flagged another serious error involving an insulin medication. That pharmacist wasn’t removed or fired either, according to transcripts.

The staff pharmacist also recalled telling a supervisor about having to handle more than 240 orders at a VA nursing home during a single shift just days before his appearance in the 2011 administrative hearing.

“I went and spoke to him and said, ‘It’s a dangerous situation there; it should not be allowed to continue,’” the staff pharmacist recalled saying. “Did I make mistakes that day? I hope not.”

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