Peter C. Harvey, Attorney General

Division of Consumer Affairs
Reni Erdos, Director

For Immediate Release:
June 3, 2004

For Further Information Contact:
Genene Morris, Jeff Lamm
973-504-6327

NEWARK — The New Jersey State Board of Pharmacy has suspended the license of Burt Friedman, a Passaic County pharmacist who was accused by the State of misreading instructions on a doctor's prescription, which led to a 24-year-old woman overdosing on a highly toxic cancer drug, Attorney General Peter C. Harvey and Consumer Affairs Director Reni Erdos announced today.

The Board suspended Friedman's license for five years — three years active; two years stayed — and fined him $10,000 after receiving an initial decision by Administrative Law Judge Robert J. Giordano and listening to oral arguments by attorneys representing the State and Friedman. The ALJ's decision, which recommended a three-year suspension, stemmed from a complaint filed by the State in 2001 alleging that Friedman's gross negligence and incompetence led to the death of Ximena Clavijo, a Paterson woman who was suffering from a malignant brain tumor. ALJ Giordano presided over hearings into the State's allegations.

In rendering its decision, the Board rejected ALJ Giordano's conclusion that Friedman's actions did not rise to the level of gross negligence, instead finding that Friedman acted in a grossly negligent manner while handling a prescription intended for Clavijo. The doctor's prescription for CCNU, a highly toxic chemotherapy drug, included written instructions that indicated that the patient should take 190 milligrams of the drug once every six weeks at bedtime, the State's complaint alleged. However, the complaint alleged, Friedman, a Registered Pharmacist In-Charge at Abel's Pharmacy in Paterson, misread the instructions and dispensed 40 days worth of the drug, providing written instructions for Clavijo to take 190 milligrams of the drug every day.

The complaint alleged that Friedman failed to adhere to written literature for the drug; failed to observe computer-monitoring programs that would indicate the 40-day supply he ordered was a duplicate order; failed to consult with the prescribing physician and failed to note the excessively high cost of the order, which exceeded $2,000.

After 21 consecutive days of taking the drug, Clavijo was taken to Wayne General Hospital suffering from bone marrow suppression, acute tonsillitis, diarrhea, and bleeding from different parts of her body. Less than two months after the prescription was filled, Clavijo died. The cause of death was attributed to the drug overdose.

"The State's complaint alleged that Mr. Friedman failed to observe repeated warning signs that he was exceeding the recommended dosage for the drug by as much as 40 times," Attorney General Harvey said. "The series of professional errors he committed was so egregious that we believe he should not hold a license to practice pharmacy in the State of New Jersey."

"Pharmacists are patients' last line of defense from prescription errors," Director Erdos said. "We expect them to take care to make sure that patients are getting the right dosage and are given the appropriate instructions on the handling of the drugs. As this case demonstrated, when they fail to follow proper procedures, they put lives at risk."

The Board's order takes effect July 1.

Deputy Attorney General Paul R. Kenny of the Division of Law handled this case for the State.

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