Dr. Sheila Caddy is a practising obstetrician-gynaecologist at South Health Campus in Calgary. In February 2024, her tracked prescription program (TPP) pads were stolen from a locked drawer in her locked office (pads 17737253-17737300). The identity of the individual who took the pads has not yet been determined, although there is a police investigation underway. The stolen TPP pads, along with the patient information listed on the pads, have since been used to forge prescriptions in Calgary and the surrounding area.
ACP has so far received 13 reports of attempted or successful forgeries tied to Dr. Caddy’s stolen TPP pads for hydromorphone and oxycodone in quantities ranging from 60 to 200 tablets.
“Most of the forged prescriptions were outside the realm of what I would consider normal prescribing practices,” said Dr. Caddy. “Most of my patients don’t go home with narcotics; if they do, the prescription is typically post-surgery for 10 to 12 tablets.”
Pharmacy teams that reported these forgery incidents to ACP noted a number of suspicious features on the forged prescriptions, including the patients’ conditions being unrelated to Dr. Caddy’s area of practice (e.g., cancer or a dislocated disc), no indications of therapy, and inconsistencies between what the patient said compared to the information on Netcare.
A number of the forged prescriptions tied to Dr. Caddy’s stolen TPP pads were filled and dispensed at community pharmacies. Dr. Caddy hopes that these incidents can be a reminder to pharmacy teams to exercise caution and to review their processes for filling narcotics.
Resources such as ACP’s Guidance for assessment and monitoring individuals using opioid medications provide pharmacy teams with valuable tools to supplement the framework for appropriate patient care outlined in the Standards of Practice for Pharmacists and Pharmacy Technicians (SPPPT).
Dr. Caddy said that she has reflected on her processes as well, as there are always learnings from these types of incidents.
“I now no longer list patient details in my prescription pad, even though that’s what I was taught to do,” she said. “Now, I just list an initial or a last name so that I can look it up if I need to.”
This change in process will help prevent patient information from falling into the wrong hands.
“Many of my patients were impersonated by these forgers and had prescriptions filled under their names, so now they have prescriptions for 160 tablets of a narcotic on their health records,” said Dr. Caddy.
Moving forward, Dr. Caddy hopes to see more open communication within healthcare teams to collaboratively prevent forgeries and protect patient information.
“These incidents really highlighted to me that maybe we need to rethink how healthcare teams communicate with each other,” she said. “We need to normalize reaching out if something is unusual or when we’re unsure.”
Dr. Caddy added that she encourages phone calls and conversations when possible.
“I think maybe we’ve lost that feeling that we should be talking instead of sending faxes or worrying that we’re bothering someone—I would be more than happy to get more calls so we can work together to prevent harm.” she said. “I think we can forget we’re all just trying to do our very best. It should be an expectation on both sides that we have open lines of communication.”
Pharmacy teams play a key role in preventing the diversion of drugs and maintaining the integrity of the drug system. A recent article in The Link outlines regulated members’ responsibilities when dispensing medication, particularly Type 1 TPP medications, in accordance with Standard 6.6 of the SPPPT.
