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Don’t cut corners

April 29, 2020
Lessons Learned: Pharmacists and licensees must always ensure patient safety is maintained.

A recent Hearing Tribunal issued its written decision on the merit and orders regarding the conduct of a pharmacist who was found during a two-week period to have singularly dispensed over 800 prescriptions daily without

  • properly conducting required daily assessments and monitoring,
  • reviewing or making notes of a significant number of patients’ Netcare information,
  • sufficiently documenting opioid treatment plans and goals of therapy,
  • identifying and responding to numerous drug errors and discrepancies,
  • successfully uploading a significant portion of his patients’ Netcare dispensing event, and
  • employing sufficient pharmacy staff to properly and safely provide service to his pharmacy’s patients.

The Hearing Tribunal also found that, for several patients, the pharmacist relied primarily on the patients’ physician to determine the appropriateness of daily dispensing.

In this matter, the Tribunal imposed the following significant penalties:

  • a two-year practice suspension;
  • $20,000 in fines;
  • the successful completion of the CPEP Probe Course, at the pharmacist’s expense, prior to reinstatement;
  • a condition that he shall not serve as a licensee, pharmacy owner, or proprietor for a period of five years;
  • a condition that upon restatement and employment as a pharmacist he must provide a copy the Tribunal’s written decision to any licensee where he practises for a period of one year and the licensee shall provide quarterly reports to the complaints director that include whether any concerns have arisen with respect to the matters addressed in the Hearing Tribunal’s written decision; and
  • the costs of the investigation and hearing to a maximum of $25,000.

It should also be noted that during the preliminary stages of the investigation the complaints director made a recommendation to suspend the pharmacy licence of the pharmacy where the pharmacist was the owner, proprietor, and licensee. This recommendation was accepted, and pharmacy’s licence was suspended on March 9, 2018. The pharmacy subsequently closed, without reopening.

Rationale for the Tribunal’s decision, is reflected in its following statements:

While there is no limit in the legislation or standards of practice regarding the number of prescriptions that can be dispensed, the context of the prescriptions dispensed must be considered.  In this case, [the pharmacist] was the sole pharmacist and employed only one pharmacy assistant.  It was not reasonable or appropriate for him to be dispensing over 800 prescriptions per day.

… … …

A pharmacist, working as the sole pharmacist with one pharmacy assistant, cannot meet the guidelines, standards and principles set out in the Code of Ethics where the pharmacist is dispensing 800 prescriptions per day.  A pharmacist working in these conditions is not capable of adequately participating in quality assurance processes or programs.  Adequate controls and checks cannot be maintained. [The pharmacist] did not have the appropriate staff in place.  Although there was no evidence of patient harm, this conduct increases the risk of harm to patients.  There were numerous drug errors or discrepancies that were not identified or responded to. The failure to upload dispensing events to Netcare also increases the risk of harm to patients, as the patient record will not be accurate.  Further, a pharmacist has a duty to determine the appropriateness of a prescription prior to dispensing it and cannot simply rely on the assessment by the physician.

… … …

Public confidence is undermined where a pharmacist practices under these conditions.

Pharmacists and licensees – review your ethical duties to our profession and yourself

  1. Licensees, review the Pharmacy and Drug Act, the Pharmacy and Drug Regulation and the Standards for the Operation of Licensed Pharmacies regarding your responsibilities in operating a pharmacy.
  2. Review and discuss your obligations and the professional requirements of the pharmacy with the pharmacy owner, licensee, and staff to ensure that the pharmacy has the resources needed to meet these obligations. Review and consider your ethical responsibilities outlined in Principle 7 of the Code of Ethics.
  3. Ensure that all records of dispensing events are uploaded onto Netcare. Many pharmacy software dispensing systems can provide alerts when records are not being properly uploaded. Consult your software provider.
  4. Don’t cut corners when it comes to providing patient care, especially for vulnerable patients.
  5. Understand that pharmacists can not rely solely on the prescription from, or assessment of, another health care provider to form their assessment of appropriateness before providing a pharmacy service.
  6. Review and discuss with colleagues your fundamental professional obligations in dispensing medications. Principles 1 to 5 of the Code of Ethics and Standards 3, 4, 5, and 6 of the Standards of Practice for Pharmacists and Pharmacy Technicians will provide you with valuable guidance in this respect.
  7. Incorporate ACP’s Opioid Guidelines into your daily practice.
  8. Incorporate ACP’s Vital Behaviours into your daily practice.