Inside a pharmacy where a fatal error occurred

JACKSONVILLE -- Lewis, then 22, a part-timer hired two years earlier, had been at the Merrill Road store for just a few months, working the evening shift. She had hoped to get a 50-cent hourly raise Walgreens offered for passing a national certification exam. But she'd failed the test.

Smith, a 46-year-old roofing contractor, suffered from chronic neuropathy pains in his legs and back. He had tried prescriptions for the painkillers Neurontin and Oxycontin. But, as he told his wife, Pearl, he didn't like the drowsiness they brought on. So on this night, the couple went to Walgreens with a new prescription for methadone, a narcotic they thought would leave him more alert.

USA TODAY's reconstruction of what happened next, drawn from pretrial depositions, interviews and Florida records, provides an inside look at the operations of a chain-store pharmacy like those relied on by millions of Americans. The reconstruction also shows what can happen as pharmacies rely on lesser-trained technicians to help pharmacists prepare prescriptions.

Lewis typed up a prescription label with erroneous dosage instructions. About 36 hours later, Smith died of what an autopsy found was an accidental methadone overdose.

It may be impossible to fix blame precisely for Smith's death, in part because Walgreens in December settled the lawsuit with his family in a confidential agreement that bars any discussion of the case. However, the depositions and interviews gathered before the settlement suggest that both a technician with limited experience and a pharmacist coping with a heavy workload figured in the tragedy.

The pharmacy was busy. Smith's prescription was among 380 dispensed on July 23, 2001.

Anna Zussy, 31, a staff pharmacist at the store that year, testified there were four hectic periods on weekdays: mornings, when patients came before work; at lunchtime; early evenings, as customers headed home from jobs; and just before the store's 10 p.m. closing.