By Joe Bukuras
CNA Staff, Oct 10, 2023 / 13:00 pm
A CVS pharmacy in Nevada that gave a pregnant woman the abortion drug misoprostol when she had been prescribed a fertility treatment has been fined $10,000 and two of its pharmacists have been penalized.
The penalties were issued last month for the incident that occurred in 2019 when the woman, Timika Thomas, a mother of four at the time, was undergoing in vitro fertilization (IVF) in an attempt to have another child.
She had just had two human embryos placed in her womb when the Las Vegas CVS dispensed the wrong prescription.
Thomas, 38, told CNA on Monday that when she realized what had happened, her first thought was, “They killed my babies.”
Abortion drug prescribed in error
Two pharmacists, along with two technicians at the CVS, committed a series of mistakes that led to the abortion drug mistakenly being given to the patient, according to documents filed with the Nevada State Board of Pharmacy.
In vitro fertilization is a process by which a human embryo is created in a lab by fertilizing mature eggs from a woman’s ovaries with a man’s sperm, according to the Mayo Clinic. That embryo is then placed inside a woman in hopes that they will implant and develop fully. The Catholic Church teaches that IVF is immoral (see the Catechism of the Catholic Church, Nos. 2376-2377).
Thomas, 34 at the time, had two embryos transferred into her uterus on July 23, 2019. Before the operation, her doctor prescribed the drug Endometrin, which contains progesterone, to aid the procedure, according to her 2019 complaint filed with the Nevada State Board of Pharmacy.
During IVF, progesterone is used to help support implantation of the embryo because the process inhibits the body’s natural ability to produce progesterone, according to Washington University School of Medicine’s Fertility & Reproductive Medicine Center.
When Thomas arrived at the pharmacy to pick up her medication, instead of Endometrin, one of the drugs that was given to her by the CVS pharmacy in north Las Vegas was Cytotec, otherwise known as misoprostol, which is often used to cause a chemical abortion.
But Thomas hadn’t checked the label on the bottle, she told CNA.
“I took the Cytotec [two days after receiving it] thinking that it was my progesterone suppositories [Endometrin],” Thomas wrote in the complaint.
Thomas said that she inserted one of the pills in the morning and then one at 6 p.m. and then began to suffer from stomach cramps.
She continued: “So I Googled the name that was on the bottle to see if that was a side effect and come to find out Cytotec is used for ABORTIONS. I was given the WRONG medication.”
“Now I might lose my two embryos that I transferred on July 23,” she wrote in the complaint.
Speaking to CNA Monday, Thomas said she called the pharmacy to complain after she had taken Cytotec. She also began searching online for how to reverse an abortion and called a hotline for abortion pill reversal.
(Story continues below)
The hotline told her she needed to take progesterone injections. CVS told her the same thing.
The next day, CVS had a technician hand-deliver the injections to her residence.
“But obviously by that time, it was too late,” she told CNA.
It’s unclear whether the Cytotec killed the babies or if the embryos just didn’t survive the IVF process. Nevertheless, Thomas’ next pregnancy test came back negative, she told CNA.
A series of mistakes
Testimony by staff at CVS and other documents filed with the Nevada State Board of Pharmacy detail a host of mistakes that led to the abortion drug being given to Thomas, who is identified in the documents as “TC.”
Haydee Martinez, a technician at the pharmacy, “performed the data entry” for Thomas’ prescription and incorrectly recorded the drug her doctor ordered as misoprostol as opposed to Endometrin, according to a case document.
The case document said Martinez mistakenly believed misoprostol was the generic drug version of Endometrin.
Another technician, Vanessa Cardozo, incorrectly entered the prescribed dosage and instructions for an antibiotic Thomas was supposed to take, the document said.
Those mishaps triggered a system warning that should have alerted the pharmacist that mistakes had been made. However, Sandra Le, pharmacy manager at the local CVS, “overrode a system warning pertaining to the data entry error relating to misoprostol,” the case document said.
In addition, on the day Thomas went to pick up the medication at the pharmacy, the pharmacist on duty, Khanh Pham, neglected to counsel the patient on the medication, according to the document.
Pham is no longer with the company, but the court documents do not explain why.
Le said in her testimony that she was alerted to the situation at 9:40 p.m. on the day that Thomas took the misoprostol by the pharmacist on duty, Chris Petersen.
Petersen became aware of the misoprostol mistake because Thomas called him in tears, upset that she had experienced cramping and concerned that she had taken the incorrect medication, according to his testimony.
Le wrote that she contacted her supervisor who told her that “we needed to get the injectable progesterone to the patient as soon as we were able to contact her.”
In abortion pill reversal, a protocol of progesterone is taken by the pregnant woman within 72 hours of taking the first abortion drug mifepristone, according to the Charlotte Lozier Institute. Chemical abortion consists of a two-pill protocol, mifepristone first and then misoprostol later.
The abortion pill reversal protocol is meant to be taken after the mifepristone because that drug blocks progesterone from the womb, according to Charlotte Lozier Institute. The organization suggests that once misoprostol is taken, an abortion will have occurred.
Once Le contacted Thomas the next day, Thomas said that she had spoken with her physician who advised her to take progesterone injections as soon as possible, Le wrote.
Le then wrote that she sent a technician with the medicine to Thomas’ residence at about 10:05 a.m. She said that she was “truly sorry for what happened to T.C.” in her testimony.
Le’s license to practice was revoked but is currently stayed, according to the case documents outlining penalties for Pham and Le.
She will only be permitted to practice pharmacy in the state on the condition that she obtain at least five continuing education credits, pay a fine of $2,000, reimburse the Nevada Board of Pharmacy of $352.20 for legal fees, and have no more violations for the next year.
Pham’s license was also revoked but stayed on the conditions that Pham obtain at least three continuing education credits, pay a fine of $750, reimburse the board of $352 for legal fees, and refrain from any further violations over the next year.
CVS was fined $10,000 and must reimburse the board $352.20 for legal fees as well.
In a statement to CNA, CVS Health spokesperson Amy Thibault said: “We’ve apologized to our patient for the prescription incident that occurred in 2019 and have cooperated with the Nevada Board of Pharmacy in this matter.”
“The health and well-being of our patients is our No. 1 priority, and we have comprehensive policies and procedures in place to support prescription safety. Prescription errors are very rare, but if one does occur, we take steps to learn from it to continuously improve quality and patient safety.”
