Inside a pharmacy where a fatal error occurred

JACKSONVILLE -- It was a busy summer night in 2001 at a Walgreens wag store here when pharmacy technician Tomario Lewis went to a computer and typed in the new prescription that would cost Terry Paul Smith his life.

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.

"If I started a shift at 8 o'clock in the morning, I would be there at 7:30. People have already called in prescriptions that they want to pick up at 8 o'clock in the morning, even though the pharmacy doesn't open until 8," said Zussy. "I got to eat on my feet sometimes, other times not at all." She said she felt so overwhelmed that the pharmacy manager, Tonya Pearson, tried to get her more work breaks.

Zussy described Lewis, the technician, as an eager employee who would ask questions about unfamiliar issues. That endorsement came with qualifications. "She wasn't one of our strongest technicians," Zussy said in a sworn deposition. "We had several that could work faster, more efficiently, more correctly."

Lewis was supposed to enter Smith's prescription with instructions to take four 10-milligram tablets, twice daily, as the roofer's doctor had instructed. But she acknowledged in her own 2005 deposition she typed directions to take the pills as needed.

Painkiller can slow breathing

The distinction was crucial. The painkiller can slow or even stop breathing and cause dangerous heartbeat changes if it's taken too often or if the dosage is too high, according to a 2006 U.S. Food and Drug Administration alert. Moreover, the FDA advised that the problems are more likely to occur when someone is first using the drug — precisely the case for Smith.

It was the responsibility of Pearson, the pharmacist on duty, to catch and correct the mistake. But she conceded in 2004 and 2007 depositions that while she could not recall checking the prescription, Walgreens' records show she verified that Smith's prescription contained the right drug, dosage and directions.

Pearson wasn't error-prone. In her depositions, she said she'd been involved with just two other drug mistakes, and both had been caught with no harm done. She said she had no complaints about the pace at her pharmacy.

Gabriella Figueroa, a former Walgreens technician who had worked the store's evening shift, said in a 2006 deposition that the heavy prescription volume and workload got to Pearson at times.

"Our store was very stressful, and … she thought it was too much for her to handle," Figueroa said of Pearson. She'd heard Pearson voice a preference for a store with "less volume," Figueroa said.

None of this was known to the Smiths when they reached the pharmacy's drive-through window around 8:15 p.m. to pick up the prescription. Pearl Smith says the transaction took less than a minute.

"Whoever it was that was working the window … came back with the prescription … and it was like, 'You don't have any questions for the pharmacist, do you?' " she said in an interview before the case was settled. "There was zero interaction" beyond that. Florida requires pharmacies to offer patients either face-to-face drug counseling with a pharmacist, or to make a written offer with toll-free telephone access to a pharmacist.

He took 22 pills before death

Smith says her husband started the prescription almost immediately. He kept a partial log that showed he took at least 22 pills over the next day and a half, nearly twice as many as prescribed.

Awakened on July 25 by roofing workers calling Terry Paul's cellphone, Pearl went to the bathroom of the extended-stay motel where the couple had been living while waiting to close on property where they planned to build a house. She found him dead, his body curled on the shower floor.

The medical examiner's office in Jacksonville contacted Walgreens for records about the prescription error soon after Smith's death. But the state pharmacy board learned about the error in 2004 only through a complaint from Pearl Smith.

After investigating, the board ruled in June 2005 that Pearson violated Florida pharmacy law "by misbranding a drug by placing the incorrect directions for use on the label." She was fined $1,000 plus $1,150 in state costs and ordered to attend error-prevention classes.

Walgreens spokesman Michael Polzin said Pearson, who still works as a pharmacist for the chain, would not grant an interview.

Lewis, answering deposition questions, said she knew methadone was a controlled substance. But she said she didn't know what could happen if someone took more than the amount directed by a doctor. "It depends on the side effects," said Lewis, who, in her deposition, said her employment was terminated by Walgreens in 2002 for reasons unrelated to the error.

Did she realize the directions she'd typed could be dangerous?

"Now, I'm aware," said Lewis.

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