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Unauthorized drug substitution not acceptable

June 24, 2020
Lessons Learned: responsible practice and professionalism can never be abandoned.

A recent Hearing Tribunal issued its written decision on the merit and orders about the conduct of a pharmacist who knowingly substituted a patient’s Suboxone dose with prednisone and then failed to care for the patient or accept responsibility for the conduct.

The Hearing Tribunal found that the pharmacist knowingly, and without authorization or proper reason, dispensed and then administered 35mg of prednisone powder to a patient who had attended the pharmacy seeking his daily witnessed dose of 16mg of Suboxone powder. After the pharmacist’s unauthorized drug substitution, she then failed to care for the patient, failed to admit to the unauthorized drug substitution, and failed to accept responsibility for her actions.

The Hearing Tribunal found that the pharmacist’s actions had, in part, created potential for patient harm, undermined the integrity of the profession, and warranted the following significant sanctions:

  • a suspension of the pharmacist’s practice permit for a period of 18 months and a requirement that the pharmacist successfully pass the Centre for Personalized Education for Professional’s Probe Course at her own cost prior to the suspension being lifted;
  • after completing the suspension and the Probe Course, and prior to being eligible to reinstate as a clinical pharmacist, the pharmacist must complete, at her own cost, the components of the Structured Practical Training (SPT) program, including all evaluations, to the satisfaction of the Registrar;
  • after completing the SPT program, and upon reinstating as a clinical pharmacist, the pharmacist’s practice permit shall be subject to the condition that she practise under direct supervision for a minimum of six months, with monthly reports to be provided by the direct supervisor to the ACP Complaints Director;
  • a $10,000 fine;
  • the pharmacist not to be an owner, proprietor, or licensee of a pharmacy commencing on the day she receives a copy of the Hearing Tribunal’s written decision and continuing for three years after she reinstates as a pharmacist;
  • the full costs of the investigation and hearing (estimated to be in the range of $27,000); and
  • the pharmacist to provide a copy of the written decision to the proprietor and licensee of any pharmacy in which she applies or works as a pharmacist for five years after she reinstates as a pharmacist.

Rationale for the Tribunal’s decision, is reflected in its following statements from its May 11, 2020, decision:

While the act of making an unauthorized drug substitution is extremely serious in and of itself, the fact that [the pharmacist] denied and attempted to a hide her conduct until the video evidence was  brought to her attention, serves to increase the seriousness and the gravity of the conduct.

The conduct of [the pharmacist] in this situation was very serious and totally unacceptable. The deliberate substitution of the prescribed drug, the lies to the patient when questioned about this, the further lies to many others who became involved at the time and at the outset not admitting any errors to key individuals including fellow pharmacists as part of the investigation, all point to a most serious lapse of personal ethics and judgment. This lapse has serious impact on the pharmacy profession and its integrity. [The pharmacist] must understand that the Alberta College of Pharmacy cannot tolerate such conduct.

It is essential that a pharmacist act with honesty and integrity. A pharmacist must concern themselves with the safety of the public. A pharmacist must be honest with their patients.

In a parallel consideration to [the 18 month suspension], the Hearing Tribunal concludes that a significant fine of [$10,000] is appropriate to reflect the severity of [the pharmacist’s] conduct, in particular, her initial attempts to hide her conduct rather than take advantage of opportunities to come clean and to take necessary steps to report her conduct and provide proper and timely care to [the patient]. This fine also sends a message to [the pharmacist] and the profession at large that this conduct will not be tolerated.

Pharmacists and Pharmacy Technicians – Incorporate these Lessons into Your Practice

  1. Review, and steadfastly practise by, the principles and guidelines laid out in the Code of Ethics with regard to your responsibilities towards your patients and your profession. Principles 1 and 10 must be the foundation on which all pharmacy professionals’ practise.
  2. Always make patient care and patient safety central to your practice.
  3. Ensure that you are aware of all standard operating policies and procedures at your practice setting(s). Resources such as the pharmacy’s policy and procedure manual and orientation training must be, reviewed, understood, reflected upon, and updated on a regular basis.
  4. When an error in judgement is made, even if it is initially intentional, do not compound that error. Take responsibility for your conduct at the earliest opportunity.