BOSTON -- Documents obtained by Team 5 Investigates show the Massachusetts pharmacy board dismisses most cases brought by patients who file complaints about prescription errors. They also do only a handful of routine inspections. And the chair and co-chair of the pharmacy board are employed by major chains.

Linda Carreiro meticulously kept track of dozens of pills her husband Jim must take to control a growing list of health problems. But she felt powerless when he fell victim to a prescription error.

"His heart starts beating really crazy," said Carreiro. "The Cartia (medication) is supposed to keep his heart rate normal."

But it wasn't until the third refill that a pharmacist at a Wareham CVS discovered Jim was getting the wrong dose.

"No, sorry. They just acknowledged the error," said Carreiro.

"I think it's pretty sad. My husband could have died from it."

The pharmacy chain remains under state oversight after dozens of people reported mistakes, but it continues to rack up complaints. There have been 59 in the past two years. The head of the pharmacy board in Massachusetts has been James DeVita, who happens to be CVS quality assurance director.

"It is totally appropriate for CVS to be represented in some way on that oversight board," said Regina Herzlinger, a health care expert at Harvard business school.

"But for its representative to chair the oversight group that's overseeing CVS? That's seems a little hard to swallow," she said.

The state says DeVita recuses himself from oversight matters and from any board business or complaints involving CVS. A company spokesman told Team 5 Investigates "members of pharmacy boards serve as advocates for public safety, not as representatives of their employers."

"You have to not only be clean, but to appear to be clean," said Herzlinger.

There is no way of knowing how many of the 84 million prescriptions are filled incorrectly every year in Massachusetts. The onus is entirely on consumers to report mistakes. In the past two years 180 people have filed complaints with the state. But Team 5 Investigates learned that more than 70 percent of those complaints were dismissed by the board of registration in pharmacy.

"The fact that a complaint is filed, there has to be evidence to support that," said Jean Pontikas, director of the division of health profession licensure. "There also has to be some evidence that would substantiate the imposition of a discipline."

In fact of those 180 complaints, just 14 resulted in disciplinary action against pharmacies. Herzlinger says reform begins with expanding the public's role on pharmacy boards. The law requires a particular makeup on the board, including one chain representative. But in Massachusetts those chain employees fill the two top spots.

The board is also responsible for inspections. But of 1,112 pharmacies, 107 were inspected last year. Many of those were prompted by consumer complaints. Only five were routine checks.

"We'd like to do more," said Pontikas. "We actually have been working on trying to accomplish that going forward."

Team 5 learned the state only employs three people to investigate complaints and do inspections.

"Random surprise inspections is the way you keep people on their toes," said Herzlinger.

A new law requires pharmacies to report prescription errors to the pharmacy board. But when the law goes into effect, pharmacists will only have to report incidents that lead to serious injury or death.

Consumers wonder if that will still let pharmacies off too easy. Bill Lyons said he's been the victim of several errors including two prescription mixups.

"I think it's expecting too much to ask them to self police," said Lyons. "It's crazy. It's got to be an independent board that manages it."