The Kentucky Board of Pharmacy has taken disciplinary actions against Med Save Pharmacy in Eminence, Ky., and its pharmacist-in-charge, Drane Stephens, following a series of compounding errors that hospitalized three pediatric patients.
The board launched an investigation Aug. 26, 2024, after receiving reports of serious complications linked to misbranded and adulterated clonidine suspensions, according to a March 17 news release. An emergency order halted all compounding at the pharmacy two days later and has remained in effect since.
The board found extensive violations of state laws governing compounding, documentation, training and quality control. Among the failures, the pharmacy compounded clonidine incorrectly using active pharmaceutical ingredient powder, failed to train or supervise compounding staff, and lacked basic documentation of compounding processes.
Under the agreed order, the pharmacy was fined $5,000, barred from compounding for five years and placed on probation for the same duration. Any violations during that time may result in permit revocation.
Mr. Stephens agreed to the board’s findings and will surrender his pharmacy license, effective May 1, 2026. He was also ordered to pay a $500 enforcement cost fee.
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