What Happened

The Pharmacy Chief at the Veterans Affairs Medical Center in Erie, Pennsylvania unlawfully obtained hydrocodone and oxycodone that were meant for veteran patients.

From January 2017 to June 2020, while serving as the facility's top pharmacy official, he removed multiple dosage units of the two Schedule II opioids from pill bottles that were awaiting delivery to VA patients. The scheme continued for more than three years before it was uncovered.

He pleaded guilty to a federal drug-law violation. Sentencing was scheduled for March 2022, with a statutory maximum of four years in prison and a $250,000 fine.

What Went Wrong

The person responsible for overseeing pharmacy controls at a VA medical center was able to divert from patient-bound medication for years. Key failures included:

  • The most senior pharmacy staff member was diverting from bottles already prepared for delivery to patients, a stage of the process with little independent double-check once the pharmacy chief has signed off.
  • A multi-year duration points to an absence of routine, independent reconciliation of outgoing patient prescriptions against pharmacy inventory records.
  • Leadership-level access to controlled substances was not subject to the same oversight applied to line pharmacy staff.

How It Could Have Been Prevented

  • Apply independent, randomized verification of prepared patient prescriptions against pharmacy records, including those prepared or approved by supervisory pharmacy staff.
  • Ensure that oversight and audit functions for controlled substances are not solely delegated to the same pharmacy leadership responsible for day-to-day dispensing.
  • Require a second qualified staff member to verify and seal patient-bound controlled substance orders before they leave the pharmacy.
  • Rotate or externally audit pharmacy leadership's own controlled-substance handling on a periodic basis, since supervisory roles are often exempt from routine peer review.

Related Guidance

Sources