It’s every pharmacist’s worst fear: To come home from a busy day at work and realize that they failed to consult with a patient about a potentially dangerous interaction, or filled a prescription incorrectly. Workers at chain pharmacies across the US have told CNN that increased demand for prescriptions, shots and other services without sufficient staff to fulfill those orders has made it nearly impossible for the workers to do their jobs properly and has created potentially unsafe conditions for customers. Mistakes happen, especially when workers are burnt out and busy. But when a pharmacist errs, the implications can be both legal – pharmacists can be sued for malpractice – and lethal. Errors can cost lives, tie pharmacists up in prolonged court battles and cost them their livelihoods. A safe workplace A 2022 National Community Pharmacists Association survey showed that nearly 75% of respondents felt they did not have enough time to safely perform clinical duties and patient care. It’s worries like these that led some pharmacists to walk out of CVS and Walgreens stores pharmacies this autumn, workers told CNN. Stores increasingly operate with just one pharmacist behind the counter for a 12-hour shift. “They didn’t feel confident that they could provide care in a safe environment,” said Michael Hogue, CEO of the American Pharmacists Association. “Pharmacists are so overwhelmed and worried that they’re going to make a mistake. It’s so easy to make a mistake under those conditions,” said Shane Jerominski, a pharmacist and labor advocate who spent a decade working at chain pharmacies including Walgreens and CVS. There’s a general misconception about what it takes to correctly fill a prescription — the work goes beyond just putting pills into a bottle. Pharmacists check prescriptions they receive from doctor’s offices for possible errors, match details on prescriptions to patient profiles, check for possible drug interactions, bill insurance companies and counsel patients. If a particular medication isn’t covered by insurance, pharmacists call doctor’s offices to try to get prior authorization or switch medications. All of that is done in between giving vaccines, ringing up and counseling customers and answering questions about over-the-counter medications. There’s a lot of room for error and the repercussions are stark. Between 7,000 to 9,000 people die in the United States as a result of a medication error each year, according to a recent National Institutes of Health study. Hundreds of thousands of other patients experience but often do not report an adverse reaction or other medication complications, the study found. The cost of looking after patients with medication-associated errors is more than $40 billion each year, according to the study. “It’s the nightmare for a pharmacist who’s had a busy shift and then goes home and processes what’s happened,” said Karl Williams, a professor of pharmacy law, ethics and counseling at the Wegmans School of Pharmacy at St. John Fisher University. “To wake up and think ‘did i remember to tell a patient about a particular risk?’ It drives people to leave the practice whether there are legal ramifications or not. If a patient has been harmed, it’s just a horrible outcome.” Legal consequences The ramifications of pharmacy errors can extend well beyond moral consequences for pharmacists. Pharmacists, said Williams, can be held responsible legally for any injuries that result from a medication error. Even if the pharmacist works for a large company with access to insurance protection and top lawyers, he said, “there’s still joint liability.” That’s because a pharmacist is a licensed professional, he said. “The pharmacist doesn’t become immune from that just because the employer is hiring an attorney. The pharmacist is still on the hook for those kinds of things.” When mistakes are reported to state boards, it’s usually the individual pharmacists who face punishment rather than the large pharmacy chains because they’re easier targets, he said. Still, he said, it’s rare that a large company doesn’t stand behind an individual pharmacist. “We defend and indemnify our pharmacists in nearly all instances,” said Fraser Engerman, a spokesperson for Walgreens. “Walgreens has a multi-step prescription filling process with numerous safety checks to minimize the chance of human error. However, when errors do occur, we also have a robust mandatory reporting system in place that allows us to quickly identify root causes and to implement process improvements to prevent future errors.” Representatives from CVS and Walgreens told CNN that patient safety is their top priority. “We foster what’s known in the health care industry as a ‘Just Culture,’ a framework that treats colleagues fairly, encouraging the reporting of errors within a protected environment without fear of punitive action,” said Amy Thibault, a spokesperson for CVS Pharmacy, told CNN. “It’s critically important to support a protected environment for our colleagues, encouraging reporting of errors and other patient safety events, ultimately improving the care we provide to our patients,” she said. Thibault said that CVS does not comment on its internal legal policy. Chain pharmacies grow About 70% of prescriptions in the country come from chain retailers like Walgreens, CVS and Walmart, according to a 2019 Drug Channels Institute report. CVS provided about 25% of all prescriptions, while Walgreens accounted for another 20%. Large pharmacies typically have liability insurance that they extend to their employees, said Gina Moore, a professor at the Skaggs School of Pharmacy and Pharmaceutical Sciences at University of Colorado. When a pharmacist is “particularly negligent” they might be held individually responsible, but those cases are very rare, she said. But pharmacists also face what Williams calls “administrative liability.” Once a pharmacist gets sued, the information becomes public. At that point, the pharmacy licensing agency gets notified and can take action against the pharmacist by removing their license — thus effectively ending their career. Still, while many pharmacies track medication errors internally, there is no federal agency that requires them to report those errors. If a pharmacy or patient does report an issue, a group called the National Practitioner Data Bank also collects information about civil liability and administrative liability cases. That information then becomes available to employers, insurance companies and other interested parties. That means pharmacists who are sued can be excluded from participating in federal government healthcare programs, Medicaid and Medicare, “which ends their career basically, even if they retain their license,” said Williams. “If they’re excluded from participation in Medicaid and Medicare, they can’t be employed by a pharmacy anymore.” It typically takes about four years of post-undergraduate study to become a pharmacist which can cost students more than $200,000. No wiggle room Tony Bertolino, managing partner at Texas-based Bertolino LLP, a law firm that specializes in defending pharmacies and pharmacists, says his clients often make mistakes because of fatigue from working long hours. “Any simple mistake: the counting of medication, or even issuing the wrong type of medication could have serious impacts and even cause a death,” he said. “There’s so much pressure on pharmacists to get prescriptions filled and to get patients in and out.” But it doesn’t matter if a pharmacist is overworked and overburdened, he added. The language of liability for pharmacy regulations is strict. “There’s really no need for the element of intent to be proven. If you break the law or violate a rule, you’re on the hook. There’s no wiggle room,” said Bertolino. “The pharmacy board will reprimand everyone involved: the pharmacy, pharmacist and pharmacy techs. They’ll go after everyone.” Strikes and union action Now a formal unionization effort, backed by the International Association of Machinists and Aerospace Workers (IAM) and pharmacy labor activists, is underway. Organizers said their efforts will target employees at CVS and Walgreens pharmacies and also extend to workers at all US retail pharmacies. “We want to find ways to help these pharmacists and pharmacy technicians to make the change that they want to see in their industry, specifically in the corporate retail giants where the problems are most acute,” said a senior official at IAM Healthcare. A representative from Walgreens added that “we are engaged and listening to the concerns raised by some of our team members. We are committed to ensuring that our entire pharmacy team has the support and resources necessary to continue to provide the best care to our patients while taking care of their own wellbeing.” CVS told CNN that executives were “focused on developing a sustainable, scalable action plan that can be put in place in markets where support may be needed so we can continue delivering the high-quality care our patients depend on.” Change is coming While there’s no federal requirement for reporting medication errors, some states are implementing regulations. Virginia passed regulations banning quotas and increasing pharmacy staffing this year that remain in effect until March 2025. Ohio has proposed rules that would also require pharmacies to adequately staff their stores. California passed AB 1286, the Stop Dangerous Pharmacies Act in October. The bill requires corporate chain pharmacies to report all medication errors and provide adequate pharmacy staffing. California’s Board of Pharmacy estimates that pharmacies in the state make about five million errors per year. But change is slow and in the meantime, the problems could be resulting in a labor shortage for pharmacists. In 2022, the healthcare industry saw the graduation of 13,323 new pharmacists, according to the American Association of Colleges of Pharmacy (AACP). That number fell from 14,223 the year prior — the largest drop in new graduates since 1983. At the same time, there were 60,882 job postings for pharmacists in the first three quarters of 2023, according to the AACP. That’s about an 18% increase from the same period in 2022.