Print Friendly and PDF Print or Download

Pharmacist Case Study Furnishing of controlled substances using false or forged prescriptions

Pharmacist License Protection Case Study with Risk Management Strategies
Presented by HPSO and CNA

A regulatory board complaint may be filed against a pharmacist by a patient, colleague, employer, and/or regulatory agency. Complaints are subsequently investigated by the regulatory board, leading to results ranging from no action against the pharmacist to revocation of the pharmacist’s license to practice. This case study involves a licensed pharmacist employed by a community pharmacy.


While at a social gathering, the insured pharmacist revealed to a friend of her boyfriend that she was a pharmacist. The individual in question told the pharmacist that he had recently been in a serious car accident and was suffering from severe pain. The individual asked the pharmacist if she could fill his prescription for him, and she agreed. Before leaving the party, the pharmacist took the prescription from the individual, and they exchanged cell phone numbers.

When the pharmacist returned to work the next day, she reviewed the prescription, noting that the prescription was for Oxycodone, Hydrocodone, and Xanax. The pharmacist called the prescribing physician’s office and spoke to someone who confirmed the legitimacy of the prescriptions. The phone call was documented on the prescription. However, the prescriptions were not legitimate and were written on a prescription pad that had been stolen from the doctor’s office. The pharmacist filled the prescriptions and notified the individual via text message from her cell phone that his prescriptions were ready.

Approximately one month later, the individual sent the pharmacist a text message asking her to refill the prescriptions. Although the pharmacist felt uncomfortable doing so, she refilled all three medications without contacting the prescribing physician’s office again to verify the legitimacy of the prescriptions.

Soon after filling the second set of prescriptions, the individual began texting the pharmacist to notify her that he was sending other people he knew to the pharmacy who also had prescriptions that they needed filled. The pharmacist filled prescriptions for at least six other individuals, with multiple prescriptions from the same prescribing physician. Each prescription was written to permit multiple refills, and the recipients paid for the prescriptions in cash. The prescriptions comprised Schedule II, III and IV controlled substances, including additional prescriptions for Hydrocodone, Xanax, and Oxycodone. All of these factors should have created concerns on the part of the pharmacist.  Nevertheless, she filled the prescriptions without contacting the prescribing doctor’s office to verify the legitimacy.

The insured pharmacist was eventually convicted on six counts of forging or issuing a false prescription and was sentenced to 240 hours of community service and three years of probation.

Following her conviction, the Board of Pharmacy (“the Board”) opened its own investigation, alleging: furnishing of controlled substances using false or forged prescriptions; use of invalid prescription; criminal conviction; and unprofessional conduct.

Risk Management Comments

The insured pharmacist expressed remorse for her actions and asserted that she was hesitant to stop filling prescriptions for the individual and his associates because she was concerned for her personal safety. The pharmacist asserted that once she became involved with filling prescriptions for the individual, she did not know how to extricate herself from the situation. The pharmacist also emphasized that she never received anything in return for filling the prescriptions, other than the customers’ cash payments to the pharmacy.

In addition, the pharmacist was able to provide letters of reference from the owners of the community pharmacy where she worked, as well as from the compounding pharmacy employing her following her dismissal from the community pharmacy. The compounding pharmacy business owners were aware of her criminal charges and the Board’s accusation and were sympathetic. The owners emphasized that she was a valuable employee.


The Board opined that the pharmacist exercised extremely poor professional judgment on multiple occasions by filling prescriptions without prescriber verification. In its decision, the Board emphasized that its administrative proceedings are not intended to punish licensees, but rather to protect the public. The Board stated that the pharmacist’s violations demonstrated serious lapses of judgment which caused harm to the public by providing controlled substances and dangerous drugs without valid prescriptions.

After consideration of all the facts and circumstances of the case, the Board concluded that the pharmacist’s license should be revoked. The pharmacist attempted to appeal the Board’s decision but was unsuccessful. The matter required more than 18 months to resolve, with incurred expenses to defend the insured pharmacist exceeding $8,400. 

(Monetary amounts represent solely the legal expenses paid on behalf of the insured pharmacist.)

Risk Control Recommendations

Pharmacists have a legal and ethical responsibility to adhere to laws and regulations, and to help protect the public from drug diversion. Pharmacists also have a professional responsibility to dispense controlled substances appropriately, guarding against potential abuse while also ensuring that patients have appropriate medication available when needed. However, despite pharmacists’ best efforts to prevent drug diversion, some individuals may successfully deceive them. Boards of Pharmacy and law enforcement expect pharmacists to perform their due diligence. The following risk control recommendations are designed to serve as a starting point for pharmacists and pharmacy business owners in managing the risks of drug diversion in community pharmacies:

Risk Control Recommendations for Pharmacists Working in Community Pharmacies:
  • Pharmacists must be aware of potential situations where drug diversion may occur and follow policies and procedures to ensure that safeguards are created and implemented to prevent diversion.
  • Understand and comply with all state prescription drug monitoring program (PDMP) requirements.
  • Understand and comply with all drug diversion reporting requirements.
  • Document all discussions with the patient, family members, the prescribing practitioner and any other appropriate healthcare personnel.
  • Contact the prescribing practitioner for questions related to a prescription, such as any ambiguity or concerns, and speak directly to the prescribing practitioner. Do not dispense any prescription for which you have validity concerns. Simply relying on acceptance from the electronic pharmacy practice system and/or approval from the patient’s health insurance does not represent a prudent practice.
  • Patient education should expressly address the potential side effects of opioid analgesics, including physical dependence and cognitive impairment.
  • Counsel each patient regarding his/her medication and document the process, including whether the patient refuses such counseling.
  • Encourage patients to ask questions regarding their medications. Respond to all such questions until patients are able to correctly repeat back the information, and document the process in their pharmacy record.
  • Know the federal, state, and local laws regarding pharmaceutical wastage of controlled substances, hazardous waste, and sharps. Select the most appropriate and secure containers and methods for safe disposal.
  • Evaluate whether workplace practices or conditions represent an unacceptable risk for patient safety or liability events. Implement appropriate corrective actions. Consider seeking alternative employment if practices are not corrected.

Risk Control Recommendations for Community Pharmacy Business Owners:
  • Implement a standardized process for screening and credentialing pharmacy staff. Credentialing should be performed on initial hiring and annually thereafter.
  • Perform at least annual performance reviews for each employee, including a review of errors, “near misses,” medication safety breaches, compliance with required documentation, and directly observed skills and competencies. Provide pharmacy staff with coaching, mentoring, and clinical and system education, on a routine basis, in order to ensure compliance with medication safety requirements.
  • Conduct regular, unannounced audits of controlled substances. All healthcare facilities, including pharmacies, should be able to account for every dose, from order generation to dispensing/administration.
  • Be alert to signs of employee drug diversion, including:
    • Disgruntled or stressed employees.
    • Employees who repeatedly come in early, or stay late, for no apparent reason.
    • Sudden, unexplained changes in an employee’s behavior, productivity, and/or standard of living.
    • Employees who frequently volunteer to witness wastage or fill prescriptions for controlled substances on behalf of their colleagues.
  • Maintain open lines of communication with staff. Staff should feel comfortable reporting workplace safety concerns, including suspected substance use or drug diversion, without fear of retribution.
  • At least annually, provide education to pharmacy staff on topics such as detecting drug diversion. Maintain records of employee education and competencies.
This publication is intended to inform Affinity Insurance Services, Inc., customers of potential liability in their practice. This information is provided for general informational purposes only and is not intended to provide individualized guidance. All descriptions, summaries or highlights of coverage are for general informational purposes only and do not amend, alter or modify the actual terms or conditions of any insurance policy. Coverage is governed only by the terms and conditions of the relevant policy. Any references to non-Aon, AIS, NSO, HPSO websites are provided solely for convenience, and Aon, AIS, NSO and HPSO disclaims any responsibility with respect to such websites. This information is not intended to offer legal advice or to establish appropriate or acceptable standards of professional conduct. Readers should consult with a lawyer if they have specific concerns. Neither Affinity Insurance Services, Inc., HPSO, nor CNA assumes any liability for how this information is applied in practice or for the accuracy of this information.

Healthcare Providers Service Organization is a registered trade name of Affinity Insurance Services, Inc., a licensed producer in all states (TX 13695); (AR 100106022); in CA, MN, AIS Affinity Insurance Agency, Inc. (CA 0795465); in OK, AIS Affinity Insurance Services, Inc.; in CA, Aon Affinity Insurance Services, Inc., (CA 0G94493), Aon Direct Insurance Administrators and Berkely Insurance Agency and in NY, AIS Affinity Insurance Agency.