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Base notifies thousands after pharmacy error

Automated refill process stopped while Wright-Patt investigates problem.


The Air Force will notify thousands of prescription drug recipients of a possible mix-up in medications after an automated process may have added the wrong pills for refilled prescriptions at a Wright-Patterson pharmacy, officials said.

The mix-up was reported at the Kitty Hawk Pharmacy, which refills about 1,000 prescriptions per day, base officials reported. Officials don’t know how many prescriptions were affected but said it was believed to be a small number.

“We’re treating it like it was a major problem” until an investigation determines the extent of possible mixed medications, base spokesman Daryl Mayer said Wednesday.

The Air Force has started an investigation to find answers, said Col. Cassie B. Barlow, 88th Air Base Wing commander at Wright-Patterson.

“The goal once again is patient safety,” Barlow told reporters.”We are very concerned about our beneficiaries, and we want to make sure all of our beneficiaries are safe.”

As a precaution, the Kitty Hawk Pharmacy ceased using an automated “robot” that refills prescriptions. Base officials have asked anyone who had an order refilled at the Kitty Hawk satellite pharmacy between April 23 to April 29 to call a hotline or come in to have the medication doubled-checked for accuracy. Prescriptions are now being filled by hand, Barlow said.

She estimated roughly up to half a percent of the prescriptions refilled may have issues among thousands of orders refilled.

“We believe just based on the number of total refills, and the number that we believe had issues, we believe the scope is very small, but it will be a few days before we know for sure,” she said.

The Wright-Patterson Medical Center pharmacy was not affected, and the concern is limited to refilled prescriptions only, base officials said.

Fairborn Mayor Dan Kirkpatrick, who retired from the Air Force in 2007 after 34 years, said he and his wife, Norma, pick up their refill prescriptions at Kitty Hawk Pharmacy every 90 days.

Kirkpatrick was planning to call in his next prescription Wednesday night and pick it up on Monday. His last assignment at Wright-Patterson was chief nurse at the medical center, and he said he’s never seen medicine problems at any Air Force pharmacy.

“Obviously, if there’s been a mix-up in prescriptions, that’s potentially very problematic,” Kirkpatrick said. “They have a very efficient system there; a check and cross-check system. I’m really surprised there’s been a mix-up. They will fix it. I guarantee it.”

The Air Force has not ordered about 100 military pharmacies to stop using the automated drug dispensing system but has instructed those “with similar equipment to thoroughly check their systems and review safety,” Larine Barr, an Air Force Surgeon General spokeswoman, said in an email.

Wright-Patterson officials did not provide a tally Wednesday of how many mixed medications have been reported. A patient called and told medical officials a prescription bottle had the wrong pills mixed in with other medication, which started the investigation, said Mayer.

An investigation by the Air Force Medical Operations Agency, the Air Force Surgeon General’s Office and the base could take about a week to conclude, officials said.

“We’re working very hard to understand what happened and to understand the scope of the issue,” Barlow said.

Base officials have asked all patients who had prescriptions refilled at the Kitty Hawk Pharmacy during the days in question to bring them back to the pharmacy or to the Wright-Patterson Medical Center information desk near the hospital’s main entrance to check for accuracy and exchange them if needed. The information desk is open from 6:30 a.m. to 7 p.m. Prescription users may call 937-257-9022 between 6:30 a.m. to 7 p.m. with questions or concerns.

Mayer said the prescriptions were a wide range of oral medications, but did not have a breakdown on the types of medication.

No patients have reported adverse reactions as of Wednesday afternoon, he said. Officials have not ruled out possible causes, including human or a shipping error, during the automated refilling process, he said.

“We’re going into it with an open mind, and we’re looking at it from stem to stern,” Mayer said.

Pharmacy personnel will contact prescription holders via telephone calls.

“We are going to contact every single person that had a refill made at the Kitty Hawk Pharmacy during that time period,” Barlow said.

The base has sent emails, put a notice on its website and posted Facebook and Twitter messages, she said.

The Ohio State Board of Pharmacy, which has oversight over civilian pharmacies and pharmacists, does not have jurisdiction over a federal pharmacy, said Jesse L. Wimberly, a state board spokesman.

“There’s so many things that we do to govern and monitor the dispensing of medication that we just don’t have that luxury when it comes to pharmacies on a federal installation,” he said.

However, the state board could become involved if it determines an Ohio-licensed pharmacist was involved in the medication mix-up, he said.

Barr, of the Air Force Surgeon General’s office, said Department of Defense pharmacies as a federal entity are not required to be licensed, but, like all pharmacies, must follow federal pharmacy laws.

Prescription dispensing errors must be reported and tracked through the Department of Defense patient safety reporting system, and Air Force pharmacies must register with the Drug Enforcement Agency, she said.

Cheri McGee, a Fairborn resident, said her parents regularly have medications refilled at Kitty Hawk Pharmacy.

Her father Francis, 85, picked up cholesterol and Alzheimer’s pills for his wife, Anna, on Tuesday. But the 90-day supply of pills were distributed in three 30-pill bottles, rather than one 90-pill bottle, Cheri said.

Francis took the medications to the medical center Wednesday, and pharmacists confirmed there was no mix-up, Cheri said.

“They were very nice about it and very apologetic,” Cheri said. “This shocked me because they’re usually very organized.”

Greg Fiely, who co-owns IHS Pharmacy & Wellness Center, advises that patients who believe they may have been affected should first look at their medication to see if it’s similar to what they regularly take.

If they have any doubt, they should call their pharmacy, and if they do not feel well, they need to visit their doctor, he said.

“A pharmacist never wants to fill prescriptions wrong,” Fiely said. “I’m sure they (Wright-Patterson) didn’t want to fill them wrong. But the technology is only as good as the humans operating them. Human error always has to be taken into account.”

IHS, which has locations in Xenia and Jamestown, upgraded to an Rx30 computer operating system about a year ago, Fiely said.

He said one prescription is scanned at least five times to check its accuracy before it’s handed over to the patient. They fill about 400 prescriptions per day, Fiely said.

“It’s helped us be as accurate as we can be,” Fiely said. “There’s always something that can happen, so the pharmacist always has to be vigilant.”


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