PC September/October 2008 - Ontario College of Pharmacists

Transcription

ontario college of pharmacists
483 Huron Street, Toronto, Ontario M5R 2R4 • Tel (416) 962-4861 • Fax (416) 847-8200
The mission of the Ontario College of Pharmacists is
to regulate the practice of pharmacy, through
the participation of the public and the
profession, in accordance with standards of
practice which ensure that pharmacists
provide the public with quality
pharmaceutical service and care.
Council Members
Council Members for Districts 1-17 are listed below according to District number. PM indicates a public member appointed by the
Lieutenant-Governor-in-Council. DFP indicates the Dean of the Leslie Dan Faculty of Pharmacy, University of Toronto.
DSP indicates the Director, School of Pharmacy, University of Waterloo.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Joseph Hanna
Elaine Akers
Sherif Guorgui
Tracey Phillips
Donald Organ
Fayez Kosa
Tracy Wiersema
Saheed Rashid
Bonnie Hauser
Gerald Cook
Christopher Leung
Peter Gdyczynski
Vacant
Stephen Clement
Gregory Purchase
Doris Nessim
Shelley McKinney
PM
PM
PM
PM
PM
PM
PM
PM
PM
PM
PM
DFP
DSP
Joinal Abdin
Thomas Baulke
Andrea Chun
Corazon dela Cruz
Babek Ebrahimzadeh
David Hoff
Margaret Irwin
Javaid Khan
Lewis Lederman
Aladdin Mohaghegh
Gitu Parikh
Wayne Hindmarsh
Jake Thiessen
Statutory Committees
• Executive
• Accreditation
• Complaints
• Discipline
• Fitness to Practice
• Patient Relations
• Quality Assurance
• Registration
Standing Committees
• Communications
• Finance
• Professional Practice
Special Committees
• Standards of Practice Working Group
• Working Group on Pharmacy Technicians
College Staff
Office of the Registrar and Deputy Registrar/
Director of Professional Development
Pharmacy Connection Editor x 241
ltodd@ocpinfo.com
Registration Programs x 250
jsantiago@ocpinfo.com
Structured Practical Training Programs x 297
vgardner@ocpinfo.com
Office of the Director of Finance
and Administration x 263
bhsu@ocpinfo.com
Investigations and Resolutions x 274
cfernandes@ocpinfo.com
Office of the Director of
Professional Practice x 236
sjackson@ocpinfo.com
Continuing Education Programs and
Continuing Competency Programs x 273
lsheppard@ocpinfo.com
Pharmacy Openings/Closings,
Pharmacy Sales/Relocation
ocpclientservices@ocpinfo.com
Registration and Membership Information:
Pharmacy Technician Programs:
Publications x 229
spark@ocpinfo.com
contents
Launching the CPD Portal
6
Becoming a Registered Pharmacy Technician
9
Blueprint for Pharmacy
12
MedsCheck: A Student’s Perspective
14
Remembering a Friend: Bob Luke
18
ISMP - Medication Safety Alert
21
ISMP - Medication Incidents Report
28
Seventeenth Annual Geriatric Report
30
Your new Online Pharmacist Annual Renewal Process
is taking shape!
33
regular features
Registrar’s Message
4
Practice Q&A
19
Registration Q&A
20
Health Canada Notices
26
SPT Q&A
32
Bulletin Board
33
Deciding on Discipline
34
Focus on Error Prevention Administering drugs to infants
45
CE Resources
46
Laws & Regulations
47
pharmacyconnection
July • August
2008
Volume
September/October 2008
Volume
15 • Number
5 15 • Number 4
The objectives of Pharmacy Connection are to communicate information on College activities and policies; encourage dialogue and to discuss issues of
interest with pharmacists; and to promote the pharmacist’s role among our members, allied health professions and the public.
We publish six times a year, in January, March, May, July, September and November. We welcome original manuscripts (that promote the objectives of the
journal) for consideration. The Ontario College of Pharmacists reserves the right to modify contributions as appropriate. Please contact the Associate Editor
for publishing requirements.
We also invite you to share your comments, suggestions, or criticisms by letter to the Editor. Letters considered for reprinting must include the author’s
name, address and telephone number. The opinions expressed in this publication do not necessarily represent the views or official position of the Ontario
College of Pharmacists.
Peter Gdyczynski, R.Ph., B.Sc.Phm.
President
Deanna Williams, R.Ph., B.Sc.Phm., C.Dir., CAE
Registrar
Della Croteau, R.Ph., B.S.P., M.C.Ed.
Editor, Deputy Registrar,
Director of Professional Development
dcroteau@ocpinfo.com
Sue Rawlinson
Associate Editor
srawlinson@ocpinfo.com
Agostino Porcellini
Production & Design / Webmaster
aporcellini@ocpinfo.com
Neil Hamilton
Distribution
nhamilton@ocpinfo.com
ISSN 1198-354X
© 2008 Ontario College of Pharmacists
Canada Post Agreement #40069798
Undelivered copies should be returned
to the Ontario College of Pharmacists.
Not to be reproduced in whole or in part
without the permission of the Editor.
registrar’s message
Deanna Williams, R.Ph., B.Sc. Phm., C.Dir., CAE
Registrar
S
ummer- so late in arriving- is
now at an end and the fall season is upon us. Summer at the
College was busier than ever, and we
expect the trend to continue this fall.
Over the summer the College has
been engaged in two significant referral processes being led by the Health
Professions Regulatory Advisory
Council (HPRAC). The first referral
was about Interprofessional Collab-
examination by HPRAC respecting
the Scope of Practice for those health
professions deemed to be most engaged in ICC: Pharmacy, Physiotherapy, Midwifery, Medical Laboratory Technology, Medical Radiation
Technology, and Dietetics. While
the College was asked to lead Pharmacy’s Scope of Practice review, our
final submission was drafted after
consultation sessions with the As-
In the next ten years... we will have even more
highly trained pharmacists and hopefully solid
‘outcomes’ data to demonstrate the tremendous
value of the pharmacist within the health care team.
oration and Care (ICC)- what is ICC,
who are the professions most actively
involved in it and how so? What are
the barriers to ICC, and what needs
to happen to give effect to models of
health care built on collaboration between these professionals? Not all
health professions lend themselves to
ICC models of care, but some- like
Pharmacy - are recognized for most
frequently engaging in communicating and collaborating with other professionals. The second referral is an
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sociation and the respective Deans
of the Schools of Pharmacy in Ontario and after considerable discussion and debate at College Council.
Both the College and the OPA made
submissions to HPRAC and these
have been posted on the HPRAC
website over the summer months
for public comment. I hope that over
the summer you took advantage of
the opportunity to participate in one
of the Scope of Practice webcasts
that the College presented- either
pharmacyconnection • September/October 2008
“live” or by viewing one afterwards
on the College’s website. The College’s submission focuses on the current scope of practice for Pharmacy
and proposes that the current statement no longer adequately reflects
how pharmacy practice has evolved
over the past three decades.The
“scope” statement is descriptive, and
we have proposed that the pharmacist’s role in health promotion and
wellness, prevention of diseases, dysfunction and disorders through medication and non-medication therapy
and the key role pharmacists play in
the monitoring and management of
medication therapy all be included in
the scope of practice statement. We
have highlighted the activities that
pharmacists are currently called upon
to do including piercing a finger with
a lancet, administering insulin by injection, or administering a substance
by inhalation –all when providing information and education to patients
or their agents respecting the proper
use of their medications, health care
aids and/or devices. Subject to certain terms and conditions, the College
proposes that pharmacists be granted
two new controlled acts- that of
“administering a substance by injection or inhalation” and that of “piercing the tissue below the dermis…..”
Pharmacists are also called upon
in daily practice to adapt or alter prescriptions- to facilitate compliance
(ie.switching- dosage forms, dosage regimen, to a reimbursable dosage form, to a commercially available dosage form); to extend prescriptions where there are no refills;
to provide prescriptions for Schedule 2 and 3 products for minor ailments; and to adjust doses in response to monitoring lab test results.
While pharmacists currently perform these activities using medical
directives, delegation or professional
judgement the College believes that
all pharmacists currently possess the
knowledge, skills, ability and judgement to perform these activities
without having to first obtain further authorization from the prescriber. Accordingly, the College is also
proposing that within the existing
controlled act of dispensing, pharmacists be permitted to “dispense a
prescription without further authorization from a prescriber subject to
certain conditions”. It is important
to know that the College has made
a conscious decision to seek an expanded role for pharmacists under
the current authorized act of “dispensing” rather than seek the new controlled act of “prescribing”. It is even
more important that you understand
why. “Dispensing” is an authorized
act that is already recognized by the
public and others as being clearly
within the pharmacist’s realm. “Prescribing” is always linked by the public and other providers to the preceding act of “diagnosing” and pharmacists are not currently trained to do
differential diagnosis. Experiences
in other jurisdictions such as Alberta
and the UK demonstrated how terminology confuses the public and
other health professions- it was not
clear in AB that pharmacists who
could “prescribe” could really only
dispense without further authorization once a diagnosis had already
been made and in many instances
once a prescription had already been
ordered. Patients who stopped in to
visit their pharmacist in the hopes of
bypassing wait times for their family
physicians were frustrated to discover that their pharmacist could not
do what they expected them to do.
The College believes there is a need
to be clear to the public and others
what pharmacists actually will be
able to do. Finally, it was important
to the College Council that the proposals capture what we believe all
pharmacists can do NOW. While
many pharmacists want to take on
a more expanded role and are capable of doing so, there are many
more pharmacists who do not support pharmacists “prescribing”. The
College’s proposals are intended to
reflect current practice, education
and competencies of pharmacists,
increase patient access to necessary services, increase efficiencies
and cost-effectiveness by decreasing
duplication, and increasing patient
compliance and safety.
These proposals require your support and most importantly, your
willingness to take on a greater role
within an expanded scope. This will
require a commitment to collaborative practice models and recognition
and further commitment that documentation of your actions/decisions
will be communicated in a timely
manner to your patients’ primary
health care providers. And of course,
these proposals will rely on a new reimbursement scheme to support the
changes and the Ontario Pharmacists Association continues to work
towards that end.
In the next ten years, when regulated pharmacy technicians are in
place to ensure a safe and effective
drug distribution system continues
and all new pharmacists are graduating with Pharm D degrees- we will
have even more highly trained pharmacists and hopefully solid ‘outcomes’ data to demonstrate the tremendous value of the pharmacist
within the health care team. And
we will then come to the point where
our partners in collaboration- other
health care professionals and our
patients will advocate for an even
greater role for pharmacists- there is
no doubt in my mind.
5
CPD portal
Launching the CPD
ONLINE ACCESS TO THE LEARNING PORTFOLIO AND SELF-ASSESSMENT TOOL
The Continuing Professional Development (CPD) portal, which has been
developed to assist OCP members in the planning and recording of continuing
education, is now available. The online portal provides access to both the
Learning Portfolio and the Self-Assessment Tool.
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Portal
Accessing the CPD Portal
To access the online Learning Portfolio or the Self-Assessment Tool through the CPD portal,
follow the steps outlined below.
1. Visit the OCP website at www.ocpinfo.com.
2. Click on the “CPD Portal” button, located in the lower left-hand corner of the OCP home page,
under FAST TRACK, to bring you to the sign-in page.
3. Your user name is your OCP number.
4. Create your password using your date of birth in the following format: MMDDYY (using numerals only).
For example, if your date of birth is September 14, 1980, your password will be 091480.
You can change your password once you have logged in.
5. Click on “Learning Portfolio” or “Self-Assessment Tool” and follow the instructions provided.
THE SELF-ASSESSMENT TOOL
T
he Self-Assessment Tool, recently revised based on
feedback from Members, is designed to help you identify the learning you need to maintain competency and to
advance professionally. The Self-Assessment Tool has five
sections: Standards of Practice, Clinical Knowledge, Practice
Environment, Frequently Asked Questions, and Education
Action Plan. Each section is described in detail below. The
first four sections help you identify your learning needs. In
the fifth section, the Education Action Plan, you plan the
learning you intend to do in the coming year. Once your
planning is complete, you will move on to the Learning Portfolio to document your activities. Note that the Education
Action Plan is the first component of the Learning Portfolio.
Any information you document in the Self-Assessment Tool
remains confidential.
Section 1: Standards of Practice
In this section, you rate yourself against a series of statements which embody the Standards of Practice. Later, once
you have completed the first four sections of the Self-Assessment, you will receive feedback on this section. You are
provided with a list of your top ten learning priorities. You
are also provided a list of the top ten items for the aggregate
of all pharmacists completing the Self-Assessment, which
allows you to compare your learning needs to those of your
peers. This information is then used to develop learning objectives and form the basis for the Education Action Plan.
Section 2: Clinical Knowledge
This section, included because clinical knowledge is a core
component of pharmacy practice, is intended to provide
you with a sense of your ability to deal with a variety of
clinical scenarios, rather than a definitive measurement of
your knowledge in any particular therapeutic area. Ten
cases, each with three multiple-choice questions, are included. Upon completion of the first four sections, you are
given feedback on your responses, identifying where further learning would be useful. As above, this information is
incorporated into the Education Action Plan in the form of
learning objectives.
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CPD portal
Section 3: Practice Environment
Education Action Plan
The third section focuses on your practice environment.
By asking you to identify your patient demographics and
common therapeutic issues and disease states encountered
in your practice, this section of the Self-Assessment helps
identify areas that you may want to focus on to enhance
competency and/or advance professionally.
This activity is designed to help you to document your
learning objectives, create a plan of action, and set a
date by which to complete the learning activity. It is most
effective when used after identifying learning needs,
which can be achieved by completing the Self-Assessment Tool.
Section 4: Frequently Asked Questions
(FAQ) Log
Continuing Education Log
In this section, you are asked to identify the questions that
are frequently asked in your practice. Through reflecting on
FAQs, you are able to identify areas where you might want
to focus your learning to improve your practice.
Section 5: Education Action Plan
In this section, you are asked to create an Education Action
Plan. By reviewing each section of the Self-Assessment Tool
and the related feedback, you identify your learning needs.
These needs are stated as specific learning objectives. You
are also asked to identify learning resources and timelines.
The Education Action Plan provides you with a learning plan
over a specified time period (usually a year).
THE LEARNING PORTFOLIO
T
he Learning Portfolio is designed to help you plan and
document your learning activities. The Learning Portfolio has four sections – the Education Action Plan, the Continuing Education (CE) Log, the Frequently Asked Questions Log and the Professional Profile. Each of the sections
is described in more detail below. If you have just completed
the Self-Assessment Tool, you will already have information
documented in the Education Action Plan section and the
Frequently Asked Questions Log. The information documented in your Learning Portfolio is confidential, unless,
on request, you have submitted your Learning Portfolio to
the College.
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Here is where you can record all of your learning activities.
Included in the CE Log is the option to complete the Learning Activity Worksheet. This worksheet will help guide you
through the learning process following any learning activity.
It will help you to focus your learning needs in the form of
an objective, to become aware of and value your learning
style, and to evaluate and reflect upon your learning experience. Most importantly, it will help you transfer your new
knowledge into your practice. These are all critical steps in
the learning cycle.
Frequently Asked Questions Log
Do you find yourself being asked certain questions again and
again in your practice and repeatedly having to look up the
answers? This optional FAQ log provides a way for you to
document those frequently asked questions. Through the
process of writing down the correct answers, you are more
likely to retain the information. In addition, this log can help
you identify areas where you may want to concentrate future learning.
Professional Profile
The Professional Profile gives you a summary of your education and other professional activities (such as delivering
presentations, authoring or contributing to papers, serving
as a preceptor, participating in professional committees,
etc). This can serve as a basis for your résumé or CV. The
Employment Record portion of the Professional Profile provides you with a place to record your past employment and
to consider how each position you held has helped you develop as a practitioner.
technician regulation
Becoming A Registered
Pharmacy Technician
The process to become registered with the College has been established, although details continue
to evolve. The basic requirements for all individuals wishing to pursue registration as a pharmacy
technician are listed below. Each step must be completed, some within the timelines described.
More information about each requirement is available on the College website.
You may wish to “Stay informed” by subscribing to e-mail notifications of new developments.
Go to www.ocpinfo.com >pharmacy technicians.
Step 1
For Individuals Currently In the Profession
Completion of the OCP certification exam or PEBC evaluation exam.
The final OCP certification exam will be administered on October 25,
2008. This exam will be replaced by an evaluation exam, administered by
the Pharmacy Examining Board of Canada (PEBC), starting in 2009. The
proposed regulations require that individuals who will not graduate from
an accredited program complete this step by January 1, 2012. This means
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technician regulation
that anyone who wishes to pursue registration and has not
already completed this step, should consider when
they plan to start the process. Details about eligibility for the PEBC exam may be accessed through the
College website once they are available from PEBC.
For Individuals Entering the Profession
Graduation from a CCAPP Accredited Pharmacy
Technician Education Program
The Canadian Council for Accreditation of Pharmacy Programs (CCAPP) has initiated the accreditation process for
Pharmacy Technician Programs and as of July 2008, there
are 7 accredited programs in Ontario. Approved education
programs in the future will only be those that have achieved
a CCAPP Accreditation. Accreditation of more programs
is expected over the next year; anyone starting a program
is advised to check if the institution is pursuing CCAPP accreditation. Graduates from an unaccredited program will
need to follow the same process as those who are currently
in the profession.
Step 2
For Individuals Currently In the Profession
Completion of the approved Bridging Education
Program
Bridging education consists of 4 continuing education courses (about 150 hours total). Limited course offerings will begin
in the fall of 2008, with roll-out of all courses planned for
January 2009. The proposed regulations require that this
step be completed by January 1, 2015. Classroom and online delivery models are being developed to promote access
for geographic and scheduling purposes.
For Individuals Entering the Profession
Completion of the Structure Practical Training
Program
The College is developing a program that will require graduates from CCAPP Accredited Education Programs to complete structured activities in a workplace setting, under the
supervision of an approved preceptor. It is expected that this
step will be ready for individuals to start in the fall of 2009.
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Step 3
For All Individuals Pursuing Registration
Completion of the PEBC qualifying examination
(written and practical components)
All applicants must successfully complete both parts of this
entry-to-practice exam. The exam is targeted to be available in 2010, with a pilot administration for a small group of
candidates in the fall of 2009. Details regarding access to
the pilot examination will be available on the OCP website soon.
Step 4
Completion of the OCP jurisprudence examination
All applicants must complete this exam, which is about the
laws that pharmacy technicians will need to abide by. It
will be administered by the College because many of these
laws are provincial and therefore cannot be included in a
national exam. The first exam will be administered in the
fall of 2009.
Step 5
Completion of the Registration process with OCP
Once the key requirements, described above, have been
met, individuals will be ready to complete their application
for registration. Documentation about other requirements,
such as demonstration of language proficiency, and payment
of fees will be included in this step.
As more details about each of these requirements becomes available, it will be posted on the College website
and email notifications will be sent to anyone who has subscribed to this service on the website.
Some Commonly Asked Questions
Q
Why is the College not “grandfathering” current
pharmacy technicians who have many years of
experience? That is what other professions have done
when they have moved to regulation.
Grandfathering is a term that is often used to describe the
situation whereby a regulatory body grants current members of a profession a license or registration without requiring
that they complete any additional education or evaluation
process to demonstrate competency in the profession.
This approach used to be common for newly regulated
professions, but only when accredited education programs
and entry examinations were already well established within
the profession. In recent years governments have chosen to
regulate evolving professions even before these entry-topractice requirements have been established. Therefore,
in the absence of accreditation processes and examinations
previously, the College requires that current members of
the profession demonstrate they have the ability to practice according to the competencies of the profession. This
expectation is consistent with the requirement that applies
to all health professionals in Ontario to demonstrate their
continued competence through their respective College’s
Quality Assurance Program.
Q
I thought regulation of pharmacy technicians
was voluntary, but I have been told I will have to
become registered. Is that true?
Although regulation is voluntary, it may be true that your
employer is requiring you to become registered. The legislation does not require all current pharmacy technicians to
become registered with the College. Individuals will have
a choice; those who choose not to become registered will
however, not be able to use the title “pharmacy technician”
and they will be restricted from doing some of the activities
that a registered pharmacy technician will be entitled to do
independently (e.g. tech check tech). It is expected that
there will continue to be a role for unregulated personnel
(e.g. pharmacy assistants) in pharmacies.
Voluntary registration also means that employers can determine their own human resource needs. Once pharmacy
technicians are regulated, employers will have a choice of
three levels of personnel; pharmacists, pharmacy technicians and pharmacy assistants. As a result, it is possible that
your employer has chosen to staff the pharmacy with only
pharmacists and pharmacy technicians. In this case your
choice to become registered may be affected by your employer’s decision, and you will have to choose to either obtain registration or look for alternative opportunities to work
as a pharmacy assistant. While it is too soon to know what
the long-term staffing mix will look like within the profession, it is a good time to start the dialogue in your own employment setting so that you can begin to make an informed
choice about becoming registered or not.
First Pharmacy Technician Education Programs Achieve Accreditation
Pharmacy Technician Education Programs have
achieved an important milestone toward the development of a self-regulating profession!
At their June board meeting, the Canadian Council for
Accreditation of Pharmacy Programs awarded the first
provisional status accreditation awards to eight Pharmacy
Technician Programs and an additional four qualifying
status awards (for programs that are still in development).
Congratulations to all of these Education Programs for
achieving this important designation.
The College is pleased to note that seven of the Provisional Status awards and three of the Qualifying Status
awards went to Ontario programs, while the other two
programs are located in Alberta. (A full listing of the programs can be accessed on the OCP website at www.
ocpinfo.com)
Graduates from programs with a provisional status
award are considered to have met the educational requirement for registration with the College, without having to complete additional courses – we have previously
described this group as our “future applicants”, but with
this latest development, the future is here!
This advancement also supports the Bridging Education Program, in that each of these accredited education
programs meets the College’s criteria to offer the required
continuing education courses for pharmacy technicians
already in the profession. Having completed the rigorous
process for accreditation, these programs are now ready
to start on the next initiative. Bridging Program courses
are starting up this fall – watch for details on the OCP
website.
11
blueprint for pharmacy
“Printed with permission from the Canadian Pharmacists Association”
Blueprint for
Pharmacy
T
he Blueprint for Pharmacy is a strategic action plan for the pharmacy profession in Canada.
The Task Force on a Blueprint for Pharmacy was established by the Canadian Pharmacists Association, in collaboration with a large number of other pharmacy organizations, in December
2006 to define a vision for pharmacy and to develop a strategic action plan for the future of the profession. The Ontario College of Pharmacists has been a member of the Task Force through the participation of Registrar Deanna Williams.
The Blueprint puts forth a new Vision for Pharmacy: “Optimal drug therapy outcomes for Canadians through patient-centered care”. The demands on the health care system and the changes in the
delivery of health care require pharmacists to focus more attention on patient-centered, outcomesfocused care to optimize the safe and effective use of medications. A summary page from the Blueprint is reprinted on the opposite (next) page.
The document, developed by the Task Force on a Blueprint for Pharmacy through extensive consultation, reviews medication use challenges and the current and future role of pharmacists and pharmacy technicians in the health care system. It also outlines the key elements and proposed actions
required to achieve the Vision and meet the future health care needs of Canadians. The actions are
grouped under five areas: pharmacy human resources; education and continuing professional development; information and communication technology; financial viability and sustainability; and legislation, regulation and liability.
The finalized document, Blueprint for Pharmacy-the Vision for Pharmacy was launched at the
CPhA annual conference in Victoria in June. You can access a copy of the Blueprint online at www.
pharmacists.ca/blueprint
Five expert working groups have now been established to further develop the implementation plans
to realize the Vision for Pharmacy. As there is activity across Canada in each of these five key areas,
the proposed actions are intended to achieve a coordinated, pan-Canadian approach to accelerate the
process. It is recognized that the delivery of health care services is a provincial mandate, and as such,
the priorities of pharmacy organizations, government and other stakeholders in each jurisdiction will
influence their approach to particular Blueprint key actions.
12
13
A Student’s
Perspective
Mena Rizkalla
“Pharmaceutical care is the responsible
provision of drug therapy for the purpose
of achieving definite outcomes that improve a patient’s quality of life. These
outcomes are (1) cure of a disease, (2)
elimination or reduction of a patient’s
symptomatology, (3) arresting or slowing of a disease process, or (4) preventing
a disease or symptomatology.” (Hepler &
Strand, 1990, Opportunities and Responsibilities in Pharmaceutical Care)
“Pharmaceutical care” is the
14
buzzword in current pharmacy prac
practice. At the end of the curriculum at the
University of Toronto, it has become
prefixed to any conversation remotely
related to pharmacy. Consequently, I
was surprised that MedsCheck oppor
opportunities are not being exercised max
maximally, that pharmacies in this Province
are doing ten each week on average.
This number is not an optimal target,
and may suggest that some pharmacies
are not participating in the program. It
raises the question of why more Meds
checks are not being done. Are there
barriers to fully implementing this pro
program across the province that were not
foreseen (such as the difficulty in small
stores, where there is only 1 pharmacist on duty at a time)? Or are phar
pharmacists simply not interested in provid
providing this service? Having spent a summer devoted to doing MedsCheck, I
have seen first hand the benefits of the
MedsCheck program to our patients
... I was surprised that
and believe that if other pharlater, this gentleman was beginmacists could see some real MedsCheck opportunities are
ning to play golf, and enjoying the
examples of making a differ- not being exercised maximally, company of his friends. He calls
ence, then it would encourthe pharmacy for any questions
that pharmacies in this
age them to give MedsCheck
related to his therapy.
Province
are
doing
ten
each
more attention and priority in
their practices. In addition, if week on average. This number Case Two:
RC is approached and asked if
patients were more aware of
is not an optimal target...
he would like a MedsCheck, he
the benefits of this program,
then the demand for it, by the public
nurse that had worked for GlaxoSmith
GlaxoSmithrefuses and says that his physician is
would further encourage pharmacists
Kline (manufacturers of Paxil(®) that
taking care of his therapy. The phar“all drugs that end with -xetine are slowly
macy student did not press the issue,
to develop this service.
frying your brain and killing you”
you”. Conaccepted the patient’s wishes, but exCase One:
sequently, he refused to take his parplained what the MedsCheck was for.
RB registers for a MedsCheck interoxetine, since he did not wish to “fry his
RC remained uninterested. Two weeks
view after being told about it by the
brain or be killed”. When he discussed
later, RC enters the pharmacy looking
pharmacist. He has depression, hyperthis with his physician, he was switched
for an enema needed for his procedure
cholesterolemia, hypertension, and
to amitriptyline but felt the physician
at the hospital the next day. The phys
physCOPD. He is showing early signs of
had treated him condescendingly. He
ician had prescribed it but not explained
Parkinson’s. RB is a widower who used
anything about the drug or how to take
believed he was being tricked into takto value playing golf with his friends.
it. Pre-procedure written instructions
ing paroxetine in a different form and
For his depression, he was prescribed
were different from those that were
did not want to hear that paroxetine is
the tricyclic antidepressant, amitriptyl‘safe’. The patient was silently refusing
on the box label. Confused, RC spoke
ine. His depression, as described, was
to take this new drug, because he “just
to the student reluctantly, and asked
considered serious. During the interdidn’t want to take that risk”.
for help. The student explained the in
inaction, each of his medications and
This may seem like a trivial drugstructions and what he ought to do.
their uses were discussed. Reasons for
related problem, but it was not triv
trivRC, grateful, asked if the student could
each medication were given, and comial from the perspective of the patient.
come to his house to do a “check thing”
pliance was inquired about. The paThe patient was disengaged from his
with his wife, who was not well enough
tient was relatively quiet initially, but
limited social network because he felt
to come into the pharmacy. The stuwhen encouraged to participate in the
withdrawn and felt that he was no
dent accepted and conducted a Medsdiscussion and discuss the medications
longer “fun” to be around. His early
Check with HC, RC’s wife. It was dishe felt more comfortable speaking. It
symptoms of Parkinson’s were makcovered through the process of Medwas noted that he had particular ining him feel further inadequate at the
sCheck information gathering that the
terest in the mechanism of action of
patient HC was often hypoglycemic,
game, and further encouraged him to
his medications, which was surprising.
withdraw. He admitted that because of
particularly early in the morning. Given
When asked if he would permit the stuthe withdrawal and lack of social ties,
the advanced age of her and her husdent to speak to his physician if necesthat he had contemplated suicide. From
band, her risk of falls, and the consesary, he was very hostile to the idea.
a pharmacist’s perspective, the patient
quences of hypoglycemia, it was decid
decidDialogue was able to elucidate the situis not receiving a drug for which there
ed that the physician ought to be conation. RB was refusing to take his amiis an indication. In one thirty-minute
tacted with a suggestion to lower her
triptyline, though punctual in receiving
encounter that included both empathy
evening dose of insulin as a start. The
refills of it. Several years previously, he
and education, this patient began takphysician’s response to this was, “What
was using paroxetine and was told by a
does the prescription say?” and after
ing his medication again. Four months
15
answering that question, “That’s what
you’re going to fill.” Discouraged by the
process, the student documented the
encounter and felt there was nothing
more that could be done at that time.
One week later, RC contacted the student to return to his home, as his wife
had just been discharged from emergency for a hypoglycemic attack. The
student then went to the physician’s
office and asked whether the physician
would now consider a change in regimen. The physician agreed, and asked
the student how the changes to the insulin regimen ought to be done.
In this case, MedsCheck became
important in several ways. First and
most importantly, the patient’s care
was looked after. Both RC and his
wife were very appreciative that someone was noticing these problems that
they were not able to assess or identify. Second, the student was able to
advocate for the patient, which was
appreciated by the patients despite
their initial hostility. Third, despite initial hostility, the physician recognised
the competence of the pharmacist, and
after the encounter, often called the
pharmacy for suggestions or prescribing advice. Fourthly, it was an opportunity for the pharmacist to exhibit his/
her role in drug information and education, as the physician was unsure of
how to change the regimen. One MedsCheck encounter led to continued patient loyalty, and respect from other
healthcare professionals.
Case Three:
GC hears about MedsCheck from a
friend at the pharmacy and asks if she
can book an appointment. GC actively
monitors her medications, already kept
16
her own list of medications, and even
had a list of all her INR values for the
previous several months. She gave the
student these values one week prior to
the interview. The student prepared
for the interview and reviewed her long
list of medications, but no significant
drug interactions seemed to be present.
She denied taking any OTC or herbal
medications, except for “the odd one
for her stomach”. All of her drugs were
optimally dosed, were the right indications, and there seemed to be no signifi
significant task for a MedsCheck interview
other than to explain the drugs, their
side effects, and inquire about com
compliance, even though it seemed clear
that she had no significant issues. The
only drug noteworthy for discussion
was her warfarin. She was receiving
a somewhat abnormal dosing of warfarin, with some days adding an extra
half-pill, on other days adding an extra
quarter, and other days just one tab
tablet. Her INR values were very inconsis
inconsistent, and were not in the target range.
During the MedsCheck interview, only
patient education was given initially.
Near the end of the interview she was
asked if she was certain that there were
no other OTC products that she was
using, because her INR values were not
consistent with the doses of warfarin,
especially given that she had been on
the warfarin for close to a year. Re
Reluctantly, she retrieved a list from her
purse of 17 herbal medications that she
was using, five of which affect her INR.
She was worried that traditional health
care providers disdained herbal medica
medications, and was not ready to give them
up. She was reassured that only those
medications that were potentially caus
causing her harm would be recommended
to be discontinued. GC received educa
education about herbals and their evidence,
and when/why health care practitioners encourage or discourage the use
of non-regulated medications. Col
Collaboratively, the student and patient
went through each herbal, discussed
the need for it, and narrowed the list
down to only three. She was happy
about this change and requested that
the student notify the nurse on her be
behalf to explain why her INR levels were
not consistent. The nurse was grateful
for the consultation, and the patient’s
INR levels were stable and therapeutic
within two to three months. She called
the pharmacy for advice before consid
considering any new herbals that her friends
would recommend to her.
In this case, an apparently “insignificant” case became significant. Drugrelated problems were discovered - the
patient was receiving drugs for which
there were no indications, and some
of her herbals were affecting both the
dosages and efficacy of her warfarin.
The opportunity for discussion that
came from MedsCheck allowed these
problems to be resolved, allowed the
patient to have more confidence in the
pharmacist, and opened the door to
interprofessional collaboration.
The point of all these cases was to
illustrate the opportunities for improved
patient care in addition to advancement
of the profession by providing the Med
MedsCheck service. Not every MedsCheck
encounter resulted in life-saving modifications, but far more often than not,
some kind of issue, even if small, was
discovered and dealt with making a dif
difference in these patients’ health and
quality of life. Patients appreciate this,
which was evident from the number of
Pharmacists have a
advancement of the profesreferrals from these patients
to their friends and family. responsibility to provide patient sion, and for building relationThese examples also demcare, and it is time that we take ships with patients by demononstrate that the public is unstrating our medication experadvantage of these initiatives. tise - the latter of which is most
aware of the benefits of this
The MedsCheck service
service. In all cases the patient
frequently challenged during
heard about it from someone
dialogues with other profesgives us that opportunity.
sions. MedsCheck interviews
else - either the pharmacist or
someone else who had had a Medsfar beyond producing an accurate
are a natural application of a pharmaCheck interview.
medication list. Both pharmacists and
cist’s knowledge and skills, and should
Not every recommendation to physnot be viewed as a burden, but as a
the public need to be more engaged in
icians was accepted or acknowledged,
standard of care. They are opportuntaking advantage of the benefits that
but again, more often than not, the
ities for alliances with patients, other
this service provides. This service crepharmacist was able to develop a relaates the opportunity for the pharmacist
healthcare practitioners, and for estab
estabtionship, that was not previously there,
to build a relationship with patients as
lishing the role of pharmacists in the
by demonstrating clinical competency
public eye as medication experts who
a knowledgeable health care provider.
and a willingness to take responsibilare directly involved in providing and
It also has a direct effect on patients’
ity for their patients care. For some,
improving patient care. Pharmacists
health and quality of life, as well as on
calls to the physician were a welcome
health care costs. It is rewarding to
have a responsibility to provide patient
the pharmacist as their knowledge and
care, and it is time that we take ad
adchange from the standard request for
a prescription clarification, a refill reskills are being applied in a patient cenvantage of these initiatives. The Medquest, or a correction of dose. By prosCheck service gives us that opportun
opportuntred approach. True, there are limitaviding the MedsCheck service pharity. It is important to determine not
tions to conducting MedsCheck intermacists were able to initiate a team aponly the barriers that are preventing
views: time or insufficient number of
proach to patient care, preventing in
pharmacists from providing this ser
serpharmacists are usually cited. What is
one case, repeated visits to the MD and
vice, but also how to overcome them.
hoped for, though, is that by recognizin another case frequent blood work,
Both the public and pharmacists need
ing the many advantages of the Medsboth of which also impact financially
to become more aware of the bene
beneCheck program, pharmacists may prion provincial health care costs.
oritize them more in their practices.
fits the MedsCheck service provides
The principal message is this: the
MedsCheck interviews are an opporin optimizing patients medications and
value of MedsCheck in practice extends
tunity for continuing education, for
health.
17
In Memoriam
Bob Luke, OCP President 1973-1975
Remembering
a Friend
I
t is with deep sorrow that we learned
of the passing of Robert (Bob) Luke
on July 17th after a lengthy battle with
ALS. Bob’s remark :” I don’t know how I
got Lou Gehrig’s Disease ... I never even
met the man!” reflects his approach to life
and its adversities.
Bob was a community pharmacy
owner in Sutton, Ontario for all of his
career. He graduated from the Ontario College of Pharmacy in 1951 and was elected to its Council in 1967. During his term, he was a member and chair of many important College committees, including Executive, Infringement
and Discipline. He served as Council President from 1973 to
1975, during which time he played a vital role in dealing with
legislative changes for health professions in Ontario which
laid the foundation for the way our profession is governed
and practised today.
Many of us who knew Bob were frequent targets of his
practical jokes that always kept us on watch and on our toes.
Bill Wensley, Don MacInnes, Jim Dunsdon, Bill Bourque
and I reflected recently on some of his pranks,which are too
numerous to recount here.
I really enjoyed Bob’s sense of humour. It was always
fun to travel to meetings with him because when the serious work day was over, you were guaranteed a fun evening. I remember him better for his kindness and leadership.
He was a long-time Board member of C.Ph.A., and elected
as its President in 1978. He was a master at working behind
18
the scenes, engineering changes for the
profession that were never documented.
He was a mentor to many and friend to
more. He was quietly very generous and
it was a privilege to be a friend and part
of his close circle of confidants.
Bob was a man of many diverse interests and talents.He served in the Royal
Canadian Navy in 1942 and served on
HMCS Uganda, the only Canadian ship that saw action
against the Japanese in the Pacific. He was a long-time
Kinsman, serving as its President, Deputy Governor and
Governor. He was appointed as Chairman of York County
Organization and Consultative Committee. He was an expert on the American Civil War, an accomplished trombonist who played with many popular bands in the war years
and more recently in a Florida Dixie jazz band.
For those who knew him well, Bob’s passing leaves us
with hearts filled with sorrow but minds replete with fond
memories of a man who was always there as a friend, leader
and entertainer. For those who did not have this privilege,
know that our profession has advanced because we can
continue to build on the work from people like Bob Luke.
We will all leave our mark on the profession as he has done.
Hopefully, we can do it with some of his flare and love of
life ... Bob would like that.
Bernie Des Roches
practice Q&A
Greg Ujiye, R.Ph., B.Sc.Phm.
Professional Practice Advisor
Logged Prescriptions
The College has received a number of comments and inquiries by e-mail, letters, and phone in response to the Practice
Q&A in the March/April issue of Pharmacy Connection. I
would like to acknowledge and thank all members who took
the time to communicate their thoughts and share their positions on the matter of logged prescriptions.
It’s encouraging to see the number and the variety of comments, positive and negative, generated by an article published in Pharmacy Connection. This reaction also highlights
the complexity of the practice of pharmacy and the variety
of opinion among members of the College.
There is no definition of “logged prescription” or “prescription put on hold” in the legislation. How such prescriptions are handled is left to the discretion of the pharmacist;
however, the number of dispensing errors and resulting complaints requires the College to address the issue.
The Q&A on logged prescriptions was intended to raise
a number of points for the pharmacist to consider when processing and eventually filling such prescriptions. It reinforces the points made in the Complaints Committee article
on logged prescriptions in the March/April issue.
The focus in both the article and the Q&A was not the
dispensed prescription, nor retrieving the original prescription, nor who checks or signs the prescription. Rather, it
was the importance of every pharmacy having procedures in
place to minimize errors and ensure a safe practice. It is the
responsibility of the pharmacist and pharmacy team in each
particular pharmacy to manage this. There are a number of
opinions on how to do so, as is evident from the comments
received; however, the final outcome must be minimization
of errors and safe dispensing practices.
Many of the comments from members expressed the
belief that the article was meant to identify a system or requirements by the College for handling logged prescriptions.
The Practice Advisory does not tell members what to do,
since this would be interfering with a pharmacist’s autonomy
as a health care provider. The intent of the Practice Q&A
is to provide guidance by bringing up points for members to
consider in dealing with practice issues. With respect to
legislation, the Q&A will provide interpretation of acts or
regulations in order to help members decide on how best to
comply with them in their daily practices.
19
registration Q&A
Chris Schillemore, R.Ph., B.Sc.Phm. M.Ed.
Manager, Registration Programs
Q
I was born and educated in Canada, but I am
doing my pharmacy degree outside of Canada
and the US. Can I register as a pharmacy student
and complete some of my credit training hours and
activities in Ontario?
In order to register as a pharmacy student in Ontario and
perform controlled acts -- such as accepting verbal prescriptions, dispensing, and conducting dialogue with patients -- under the direct supervision of a pharmacist, you
must meet the OCP’s eligibility requirements. Pharmacy
students must be enrolled in an undergraduate pharmacy
degree program accredited by the Canadian Council for
Accreditation of Pharmacy Programs (CCAPP) or the Accreditation Council for Pharmacy Education (ACPE) If
your pharmacy program is not accredited by either CCAPP
or ACPE, you are required to do the following before you
may register as a student:
• demonstrate your English or French language proficiency
• have your documents favourably evaluated by the Pharmacy Examining Board of Canada (PEBC) and successfully complete the PEBC’s Evaluating Examination
• successfully complete Canadian Pharmacy Skills 1 (CPS
1) of the International Pharmacy Graduate (IPG) program
offered at the Leslie Dan Faculty of Pharmacy at the University of Toronto.
Successful completion of Canadian Pharmacy Skills II
(CPS II) is required before you are eligible to register as a
pharmacy intern in Ontario.
In your case, if you would like to work in a pharmacy in
Ontario before you graduate, your function will be limited
to that of a pharmacy assistant rather than of a pharmacy
student.
20
When you eventually go to register as a student, you may
demonstrate language proficiency by providing non-objective evidence to a panel of the Registration Committee. An
example of non-objective evidence might be a letter from a
Canadian school board confirming that you attended grade
school and secondary school here.
Q
I’ve heard that OCP has “lowered” the minimum
score it requires on English fluency tests for any
non-native speaker wishing to register as a student.
Is this true?
Language proficiency tests can vary between different administrations and versions of the test. Most testing institutions have published a standard error of measurement
(SEM) to take this into account.
The current minimum scores on the language proficiency tests accepted by the OCP were determined with NAPRA and the other provincial regulatory authorities. Any
exceptions to these minimum scores must be determined
by a panel of the Registration Committee on an individual
or “case-by-case” basis.
Panels have begun to consider fluency test scores within
the SEM as non-objective evidence of language proficiency. Simply submitting test results that are below the minimum scores, but within the SEM, may or may not convince
a panel that you have met the OCP’s language proficiency
requirements. If you are requesting consideration of test
scores that fall within the SEM from a panel, you should
submit additional evidence to demonstrate your English
language proficiency. For examples of other evidence that
have been considered by panels, please see www.ocpinfo.
com > Licensing > Tests & Assessments > Fluency > Other
Evidence of Language Proficiency.
21
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23
24
25
health canada advisories & notices
25 June 2008 Becton Dickinson is recalling Tensor Heat Therapy due to customer reports of skin irritation and burns surrounding the product.
24 June 2008 Nangen Zengzhangsu (may also be known as Nangen or Nangeng), Sanbianwan, Jiu Bian Wang, Tian Huang Gu Shen Dan, Zui Xian
Dan Gong Shi Zi, and Power Up. The Hong Kong Department of Health has warned consumers not to use these herbal/proprietary
Chinese medicine products promoted for erectile dysfunction because they have been found to contain sildenafil and/or glibenclamide.
Zhong Hua Niu Bian. Zhong Hua Niu Bian is an herbal/proprietary Chinese medicine product promoted for erectile dysfunction.
Singapore’s Health Sciences Authority has warned against the use of this product because it has been found to contain sildenafil,
glibenclamide, tadalafil and sibutramine, prescription medications that should only be used under the supervision of a health care
professional.
23 June 2008 A study recently published in the The Lancet suggests that patients infected with HIV and who are currently using or have recently
used (within the past 6 months) abaca-containing drugs may have a potential increased risk of myocardial infarction.
20 June 2008 Pfizer Canada in collaboration with Health Canada would like to notify healthcare professionals of important safety information
regarding CHAMPIX, and post-marketing reports of serious neuropsychiatric adverse events, including depressed mood, agitation,
hostility, changes in behaviour, suicidal ideation and suicide, as well as worsening of pre-existing psychiatric illness (previously
diagnosed or not).
18 June 2008 Do not to use the dietary supplements 6-OXO(4-androstene-3,6,17-trione) and 1-AD (1-androstenediol), or any other supplements
containing the ingredients 4-androstene-3,6,17-trione or 1-androstenediol, due to potentially serious health risks such as seizures and
blood clots in the brain that can lead to disability.
12 June 2008 Health Canada has been informed that some medical devices have been coated with contaminated heparin. The risk associated with it
is not known but adverse reactions may include allergic and anaphylactic reactions. Health Canada makes recommendations to health
care professionals in this regard
10 June 2008 Liver enzyme elevations above 10 times normal were found in a larger proportion of patients using Somavert(pegvisomant) in
combination with octreotide acetate for the treatment of acromegaly compared to patients taking either drug alone. This combined
use is not authorized in Canada.
6 June 2008
There have been rare reports of serious liver injury in patients receiving Tysabri, occurring as early as 6 days after first dose. Tysabri
product label has been updated for liver injury, hypersensitivity reactions and herpes infections.
6 June 2008
Following a communication issued to Canadians on May 22, 2008, Health Canada is advising consumers that an additional lot of the
product Desire has been found to contain an unlabelled prescription drug. This unauthorized product is promoted to enhance male
sexual performance and may pose serious health risks in certain patients.
2 June 2008
Important Safety information on Medtronic Cardiopulmonary Bypass Devices. Medtronic has published a notification to inform users
that selected cardiopulmonary bypass products coated with the Trillium process may contain contaminated heparin. The risk associated
with the products is small and they can continue to be used
26 July 2008
Health Canada is advising consumers not to use 4 foreign health products due to concerns about possible side-effects: Wodibo, VirilIty-Power (VIP) Tablets, Therma Power (red and blue varieties) and Grenade Fat Burner.
26 July 2008
Sandoz Canada is conducting a voluntary recall of the prescription drug Sandoz Timolol Ophthalmic Solution in 0.25% (DIN
02166712) and 0.5% (DIN 02166720) strengths, because some bottles may contain more of the active ingredient (timolol maleate)
than indicated on the label, exposing patients to an increased risk of adverse events.
26 July 2008
There is a possibility that bottles of ratio-Metformin 500mg lot 638812 may contain stray tablets of ratio-Lovastatin 40mg.
23 July 2008
Health Canada is warning consumers not to use the unauthorized product Jin Bu Huan Anodyne because it contains the undeclared
ingredient tetrahydropalmatine, which has been associated with serious adverse health effects.
22 July 2008
Health Canada is informing Canadians of additional information on Wild Vineyard products that pose a risk to health. These products
have been found to contain unacceptable levels of bacterial contamination and/or heavy metal contamination, such as lead. In
addition, some of these products are inappropriately labeled.
18 July 2008
Health Canada is warning consumers not to use the prescription drug Sandoz Timolol Ophthalmic Solution in 0.25% and 0.5%
strengths, because some bottles may contain more of the active ingredient (timolol maleate) than indicated on the label, exposing
patients to an increased risk of adverse events.
18 July 2008
Ferring Pharmaceuticals and Health Canada are informing Canadians that nose sprays or solutions of desmopressin should no longer
be used for the treatment of primary nocturnal enuresis (bed-wetting) due to an increased risk of hyponatremia (low blood salt levels).
26
18 July 2008
Health Canada is advising Canadian retailers not to sell and consumers not to use manual toothbrushes labeled as Oral-B Classic 40
Medium, as they were found on the Canadian market and may pose harm to consumers.
14 July 2008
Ratiopharm is conducting a voluntary recall of 54 lots of ratio-Morphine SR (Morphine sulfate sustained release) 15 mg, 30 mg and 60
mg tablets (DIN 02244790 - 02244791 - 02244792) due to the possibility that they may contain oversized tablets.)
11 July 2008
Health Canada is advising Canadians of reported malfunctions with the Twinject 0.3 milligram (mg) auto-injector and the Twinject
0.15 mg auto-injector that may pose serious health risks to users.
11 July 2008
Hoffmann-La Roche Limited, in consultation with Health Canada, has informed Canadian healthcare professionals of important new
safety information concerning the use of AVASTIN® (bevacizumab) in combination with sunitinib malate.
11 July 2008
Health Canada is advising consumers not to use unauthorized drugs sold by the company Purepillz. Four unauthorized
products, “Peaq”, “Freq”, “PureRush”, and “PureSpun” are promoted on the company’s Web site as “social tonics” and are
described as “safer legal alternatives to more dangerous street drugs.” The products contain benzylpiperazine (BZP) and
3-trifluoromethylphenylpiperazine (3-TFMPP), and may pose serious health risks.
11 July 2008
Product D12302M lot W8D23D0 may be mislabeled with information from product D12294M lot W8D23D1. The resultant risk
is cardiac arrhythmia due to patient exposure to dialysis concentrate concentrations of potassium one half of that expected. Both
product codes and lots have been recalled.
9 July 2008
Health Canada recalled Ratio-Morphine SR Tablets due to risk of accidental overdose and is warning consumers not to use the
prescription drug in 15 milligram (mg), 30 mg, and 60 mg formats. Some tablets may contain more morphine than the label indicates,
exposing patients to the potential risk of accidental overdose. Oversized tablets that are noticeably thicker than the regular tablets,
and which may contain more morphine than the strength indicated, have been found on the Canadian market. Ratio-Morphine SR
tablets are taken orally for the relief of severe pain.
7 July 2008
Super Shangai Strong Testis, Shangai Ultra, Shangai Ultra X, Lady Shangai, Shangai Regular (also known as Shangai Chaojimengnan),
Actra-Sx, An unknown product containing the plant Lycium barbarum L., Adam Free, NaturalUp, Erextra, Yilishen, Blue Steel, Hero,
Naturalë Super Plus. These products are not authorized for sale in Canada and have not been found in the Canadian marketplace, but
it is possible they may have been brought into the country by travellers or purchased over the Internet.
2 July 2008
The Health Sciences Authority of Singapore has warned consumers not to Arthrit Indica because it contains nimesulide, a
pharmaceutical ingredient that has been associated with liver damage. The U.S. Food and Drug Administration has warned that
Mommy’s Bliss nipple cream contains the preservatives chlorphenesin and phenoxyethanol, which could cause serious side-effects,
including difficulty breathing and dehydration, if ingested by nursing infants.
2 July 2008
Health Canada continues to monitor reports of serious adverse reactions (ARs) suspected of being associated with fentanyl
transdermal patches. Fatal outcomes were previously described in this newsletter involving opioid-naive adolescents and adolescents
who abused this medication.
For complete information & electronic mailing of the Health Canada Advisories/Warnings/Notices subscribe online at:
http://www.hc-sc.gc.ca/dhp-mps/medeff/index_e.html
MedEffect e-Notice is the new name which replaces Health Canada’s Health_Prod_Info mailing list.
The content of the e-notices you receive will remain the same and are now part of MedEffect, a new Health Canada Web site dedicated to
adverse reaction information. MedEffect can be visited at www.hc-sc.gc.ca/dhp-mps/medeff/index_e.html
Health Canada Notices are also linked under “Notices” on the OCP website: www.ocpinfo.com
27
ismp canada
Medication Incidents Reported to OCP
A REVIEW BY ISMP CANADA
Submitted by Certina Ho, BScPhm, MISt, MEd
Medication Safety Specialist, ISMP Canada
I
n a collaborative effort to enhance medication safety
in community pharmacy practice, the Institute for Safe
Medication Practices Canada (ISMP Canada) reviewed
medication incidents reported to the OCP Complaints Committee and offered recommendations in response to the
data analysis.
As of July 2008, ISMP Canada has reviewed 229 reports
of medication incidents reported to the OCP Complaints
Committee from 2001 to 2007. The goal of this review was
to seek trend information that may assist in identifying system issues and strategies that are useful to both OCP and
ISMP Canada in supporting community pharmacists to reduce the risk of medication incidents.
This report highlights the most significant findings from a
quantitative analysis of these 229 medication incidents with
a focus on two main areas:
o severity of outcome of medication incidents
o medication-use areas associated with incidents
With the small number of incident reports in this review,
results cannot be extrapolated to be a true reflection or
representation of community pharmacy practice issues. It
does however signal the nature of some of the medication
incidents that occur and possible contributing factors associated with these incidents.
Severity of Outcome of Medication
Incidents
Although most of the medication incidents during the period
analyzed were not associated with patient harm or death,
the proportion of events associated with harm or death
(25.76%) does represent a substantial absolute number of
patients. These events would have required considerable
extra healthcare resources for treatment, in addition to the
grief and suffering caused to the patient and the family.
28
Medication-Use Areas Associated
with Incidents
Stages of Medication Use
This analysis indicated that the dispensing/delivery stage accounted for most of the medication incidents reported to the
OCP Complaints Committee; another important medication-use area was the order entry/transcription stage. One
possible explanation for this pattern may be that these two
stages are the core work processes that happen in a typical
community pharmacy setting. In addition, since a majority
of these incidents were discovered and reported to the OCP
by patients or patient care givers, it is unlikely that the other
stages of medication use (for example, prescribing, administration, and monitoring) would be recognized.
Types of Medication Incidents
The most common types of error were incorrect drug, followed by incorrect dose and incorrect strength/concentration. A number of factors contribute to incorrect drug
and incorrect dose errors, including use of dangerous abbreviations, look-alike and sound-alike drug names, lookalike packaging, and proximity of storage. ISMP Canada
has undertaken work to address many of these issues. For
instance, a list of dangerous abbreviations pertinent to Canadian healthcare was developed and has been published
(see http://www.ismp-canada.org/dangerousabbreviations.htm).
Top 10 Medications
Comparing the 10 most frequently reported medications and
the top 10 medications reported as causing harm or death, it
is likely that prednisone, warfarin, furosemide, atenolol, and
clarithromycin may be the “red-flag” medications in community pharmacy setting. Further research or analysis with
a larger sample size of medication incidents is necessary in
order to provide a better picture of high-risk medications in
community pharmacy.
Drug Utilization Issues
Confusing drug name/label/packaging, pediatric and chemotherapy drugs accounted for a significant proportion of the
medication incidents. This finding with respect to confusing
drug name/label/packaging corresponds to the analysis as
mentioned above in Types of Medication Incidents. In addition, pediatric and chemotherapy drugs are also potential
“red-flag” medications in the community pharmacy setting.
Possible Causes
The most common causes associated with medication incidents in community pharmacy were lack of quality control
or independent check systems, environmental, staffing, or
workflow problems, drug name, label or packaging problems, staff education problems, and miscommunication of
drug orders.
Limitations
There are several limitations to the results of the quantitative data analysis reported here.
o No statistical analyses were done, and it is therefore impossible to completely rule out chance as an explanation
for the results, particularly given the small sample size.
o This report only reviews medication incidents that were
brought forward to the OCP Complaints Committee,
with a majority of them being discovered and reported
by patients or patient care givers. Therefore, it cannot be
used to obtain a true estimate of the rate or type of medication incidents in the community pharmacy setting.
o The validity of inferring the degree of risk for a particular
medication from the low number of medication incidents
associated with it is uncertain, given that a higher number
of reports may simply indicate widespread use of the drug.
To balance the purely quantitative nature of the data analysis reported here, it might be more appropriate to study detailed descriptions or investigation reports of specific medication incidents and to analyze this data qualitatively.
As the sample size is small, continued compilation and
analysis of medication incidents from community pharmacy
would provide a more valuable data source, including encouraging community pharmacy practitioners to report directly to ISMP Canada through the online Medication Incident and Near Miss Reporting Program at the ISMP Canada
Web site (https://www.ismp-canada.org/err_report.htm).
Collaborative analysis with ISMP Canada would assist in
identifying emerging trends in medication errors as well as
the type of factors that can contribute to causing errors in
this particular setting. Through analysis of incidents and
dissemination of information, practitioners can learn from
reported incidents and implement safeguards. Creating a
culture of patient safety (expressed through the behaviours,
beliefs, and values of people in the workplace, and the systems and processes in place to manage safety) needs to be
encouraged within all areas of pharmacy practice. Enhancing the understanding of why human error occurs, and the
conditions which provoke it in all health care environments
is a goal of ISMP Canada.
Recommendations
The following recommendations are offered by ISMP Canada in order to increase the awareness of safety issues in
community pharmacy practice.
1.Report medication incidents and near misses or good
catches to the online Medication Incident and Near
Miss Reporting Program at the ISMP Canada Web site
(https://www.ismp-canada.org/err_report.htm) for the
purpose of shared learning.
2.Implement the Medication Safety Self Assessment Program (MSSA) for Community/Ambulatory Pharmacy
(see http://www.ismp-canada.org/amssa/index.htm)
to identify system improvement opportunities.
3.Participate in ISMP Canada education programs for community pharmacists, which include general medication
safety principles (e.g. Medication Safety Self Assessment or MSSA), analysis of error situations (e.g. Root
Cause Analysis or RCA http://www.ismp-canada.org/
rca.htm), and assessment of work environment, equipment and procedures proactively to identify potential
error sources (e.g. Failure Mode and Effects Analysis or
FMEA http://www.ismp-canada.org/fmea.htm).
4.When relevant, engage ISMP Canada to assist with completing a root cause analysis for critical incidents.
5.When contracting relief pharmacist(s) through an agency,
ensure that the relief pharmacist(s) are aware of the most
common sources of errors and offer guidance to them in
the event that an incident occurs during their shift(s).
29
geriatric report
Seventeenth Annual Report of the
Geriatric and Long Term Care
T
he committee has just completed its review of 2006
cases which were referred to the Chief Coroner’s
office. The final report, including recommendations
where indicated, are sent back to the local community for
discussion and implementation with the aim of preventing
future deaths in similar circumstances. We are reprinting
the general recommendations regarding the use of drugs in
the elderly for information of pharmacists providing care to
elderly and long term care patients. The complete report is
available online at www.ontca.ca
THE USE OF DRUGS IN THE ELDERLY
• Total Number of Cases Reviewed – 2006: 27
• Total Number of Cases with Recommendations Related
to this Topic Area: 8
1. Health care professionals should be reminded that dysphagia is a complex and common problem in the elderly. When assessing an elderly patient with dysphagia,
health care professionals should conduct a comprehensive assessment looking for all potential causes of the dysphagia. Included in this review should
be a critical review of the patient’s medical profile.
For example, calcium channel blockers such as Verapamil Hydrochloride may impair esophageal contractility
which could cause and/or worsen a dysphagia. In addition, Metochlopramide, an upper gastrointestinal motility modifier, may produce Parkinsonian symptoms in the
elderly including impaired swallowing.
2. Health care professionals should be reminded of
the importance of not prescribing medications with
30
anticholinergic properties such as Diphenhydramine
Hydrochloride and Ranitidine Hydrochloride to elderly
patients. When medications with anticholinergic properties are prescribed, their use should be directed towards
managing a specific clinical symptom or symptoms and
duration of their use should be minimized based on the
elderly patient’s clinical response and/or the development
of side effects. Where possible, alternative medications
without anticholinergic properties should be used preferentially in the elderly.
3. Health care professionals and especially health
care professionals working in the emergency
room setting should be reminded of the importance of having a full understanding of the pharmacokinetics of narcotics prescribed to control pain.
For example, the lowest possible dose of short acting narcotics such as Morphine Sulfate should be
the initial dose with increasing doses titrated upwards depending on the patient’s clinical response.
The use of long acting narcotics may also be of benefit
but their dosage and timing between doses must be carefully monitored and in keeping with recognized medical
practice.
4. Health care professionals should be reminded of the importance of watching for the development of side effects
of medications prescribed for elderly patients with impaired hepatic or renal function.
5. Health care professionals should be reminded that the
Fentanyl transdermal patch should only be prescribed to
opioid tolerant patients. If a patient develops side effects
Review Committee 2007
such as unresponsiveness or a decreased level of consciousness, the patch should be removed immediately
and consideration should be given to the use of a narcotic
antagonist.
6. Health care professionals should be reminded of the
benefits of anticoagulation therapy for elderly patients
undergoing surgical repair of a fractured hip. When anticoagulation therapy is not prescribed, documentation on
the medical record of the reasons for not using anticoagulation therapy should be mandatory.
7. Health care professionals who prescribe nonsteroidal
anti-inflammatory agents in the elderly should be reminded of the benefit of using less toxic alternatives such
as Acetaminophen for the post-operative management
of pain.
8. Health care professionals should be reminded of the potential risks of ordering diuretics. When diuretic therapy
is indicated, ongoing clinical and laboratory monitoring
of the patient should be considered on a case-by- case
basis.
9. When prescribing diuretics for the elderly, health care
professionals should be reminded of the importance of
ensuring that the initial dosage is the lowest possible dosage with further doses titrated upwards depending on the
patient’s clinical response to the diuretic.
10. Health care professionals should be reminded that low
dose Hydrochlorothiazide is an effective antihypertensive
but not an effective diuretic. When Hydrochlorothiazide
and Furosemide are prescribed together, health care professionals need to carefully monitor the patient for evidence of the development of side effects. Once the desired effect has been reached, consideration should be
given to discontinuing the Hydrochlorothiazide.
11. Health care professionals should be reminded of the risks
of ordering a thiazide diuretic in combination with a loop
diuretic such as Furosemide. When prescribed, the patient should be closely monitored for the development of
side effects. Once the patient has clinically stabilized and
the diuretic is no longer needed, consideration should be
given to discontinuing the medication.
12. Health care professionals should remember the importance of regular reassessment of long term medications
as a patient ages. Aging patients who may tolerate certain medications and doses when they are younger may
subsequently manifest adverse effects of the same medication regime due to the aging process.
13. When prescribing major tranquilizers such as Chlorpromazine, health care professionals should be reminded
of the importance of monitoring not only the beneficial effects of the medication, but also the potential adverse effects such as altered mobility, falls, interference
with swallowing, paradoxical agitation, constipation,
and urinary retention.
14. Health care professionals should be reminded that
chronically constipated elderly patients taking neuroleptic medication are at an increased risk for the development of a colonic volvulus.
31
structured practical training Q&A
Diana Spizzirri, R.Ph., B.Sc.Phm., M.Ed.
Penny Tsang, R.Ph., B.Sc.Phm.
Deanna S. Yee, R.Ph., B.Sc.Phm., M.Sc.
Registration Advisors
Q
As an SPT preceptor, I know that I can supervise
only one student or intern at a time. My intern
has completed the minimum training period to
my satisfaction, and mailed in his activities and
assessments this week. How soon can I take on
another student or intern?
SPT activities are reviewed by a Registration Advisor or external pharmacist reviewer within three weeks of their receipt. Once an intern has submitted his or her activities and
final assessments, he/she should also submit a pharmacist
application form and the applicable fees. While the intern’s
activities are being reviewed, Client Services staff will be
able to review the intern’s file for any outstanding documents or fees, and notify the intern if necessary.
When the activities and assessments have been approved,
SPT staff will inform the intern and Client Services staff that
the intern’s training has been successfully completed. Your
intern should share this information with you. You will then
be able to act as a preceptor for another student or intern.
Q
I am working on my SPT internship activities.
Do I need to provide references for all of the
activities? How should I cite them?
References should be cited for all SPT activities. Doing so
demonstrates to the SPT reviewer that you have access to
current references and are familiar with drug information
resources. SPT reviewers are also looking for evidence that
you rely on unbiased references and can research the material without your preceptor’s assistance, in preparation for
your independent practice as a pharmacist.
Examples of the recommended format for citing references are provided on page 32 in the SPT Handbook (blue
cover). The SPT Handbook is available on line for pharmacist members at www.ocpinfo.com > Licensing > Training
& Assessments > “SPT Manuals.” Your preceptor will be
required to log in to the website.
At a minimum, the reviewer should be able to quickly
retrieve the same information that you used to complete
the activity without having to search for it. When citing
legislative references for the Assuming Ethical, Legal and
Professional Responsibilities (ELP) activities, you should
32
provide the name of the legislation, the year of proclamation and the numerical reference to the specific portion of
that legislation.
Q
I am an international pharmacy graduate and
have just started my SPT studentship. My
preceptor and I are unsure about what we need to do
and when. Could you please give me some guidance
as to how I should organize the activities and
assessments?
On the first page of the SPT Studentship Manual (yellow
cover), there is a Studentship Rotation Checklist. It is a
timeline of the assessments you and your preceptor should
be completing and submitting to OCP. You may wish to
cross out or highlight each row as you complete the Action
Item so that you will know what you need to do next. For
the formal assessment forms that are to be completed every
four weeks, you and your preceptor should each complete
your own copy of the forms, then meet to discuss your assessments. Both of you should provide examples to support your ratings. Once you have discussed the assessment
forms, each of you should sign the other’s copy. For the Target Objective Conference forms that are to be completed
in between the formal assessments, you should complete
the form on your own, then discuss it with your preceptor
and ask him or her to write additional comments. Samples
of written feedback can be found on pages 45 to 48 of the
SPT Handbook (blue cover).
On page 5 of the SPT Studentship Manual, there is a
Sample Activity Planning Schedule. While you are not required to follow it exactly, it will give you an idea of what
activities you should be working on each week.
At least twice a year, the Registration Advisors hold a
seminar at OCP about the SPT program for international pharmacy graduates who have registered or are eligible
to register as pharmacy students. For information about
an upcoming seminar and details about how to register,
please contact Vicky Gardner, SPT Administrative Assistant, at vgardner@ocpinfo.com, or watch for a flyer on the
homepage of the OCP website.
moving forward with technology
Your new Online Pharmacist Annual
Renewal Process is taking shape!
In anticipation of the Online Pharmacist Renewal Process
being launched early in 2009, (and further to the overview
in the last issue of Pharmacy Connection), we want to keep
you informed of our progress - with a sneak peek at the look
and feel of this new technology.
This new application will take you through the process of
annual renewal step-by-step. Each section that you complete
will automatically advance you to the next required section.
As you complete each section, you’ll notice that the tabs will
change colour (i.e. turn to grey ). This means the application
has a memory feature; you’ll always know where you are in
back online at a later point to complete your renewal.
the process by the colour of the tabs completed. You may find
Stay tuned for more details on the new online renewal process
this convenient, should you be interrupted and need to come
in the November issue of this publication.
bulletin board
The College bid a fond farewell to Brian Brophey, Discipline Case Coordinator in the Investigations and Resolutions Department. After almost 7 years with the College,
Brian has decided to move on to new challenges. We wish
him all the best in his new endeavours.
Pauline Rosenbaum, who was hired on a temporary contract in early February as the Acting Decisions Coordinator in the Investigations and Resolutions department has
joined the College on a permanent basis in the Discipline
Case Coordinator role.
SooJeen Park recently joined the College in the Office
Services Department as the Reprographics Clerk. SooJeen comes to us with a good background of customer
service experience and a familiarity with office technology, both of which will help him reach the very high service expectations in this role.
Jessie Dufour joined the College in June as a Pharmacy
Inspector. Jessie has community pharmacy experience,
both as a staff pharmacist and a pharmacy manager.
Additionally, she has head office experience with a national grocery store chain, being responsible for numerous
new store openings in Ontario. She is also involved with
the IPG program as a Teaching Assistant.
Reunion - Class of 7T8
30th year Reunion Dinner, including a tour and cocktail
reception at our new Faculty building!
Saturday, September 27th
Please contact Doris Kalamut at doris.kalamut@utoronto.
ca or 416-485-2067.
More information will be mailed.
33
deciding on discipline
Case 1
Non-supervision of a pharmacy,
sale of prescription medication
without a prescription, sale of nonapproved natural health products,
recordkeeping deficiencies
Member: Jayant Patel
Pharmacy: Leamington Wellness
Pharmacy, Leamington
Hearing Date: June 23, 2008
Facts
Mr. Patel was the owner, Designated
Manager, and a dispensing pharmacist
at Leamington Wellness Pharmacy
in Leamington. The accredited pharmacy is on the first floor of a twostorey building located in downtown
Leamington.
A relief pharmacist who had
worked at the pharmacy contacted
the College and expressed concerns
that the pharmacy had been operating without a pharmacist being physically present.
In July 2006, a College investigator attended at the pharmacy but did
not identify himself as an investigator.
He observed that the pharmacy was
open although no pharmacist was
present, and that the pharmacy was
staffed by non-pharmacist employees. He was advised that Mr. Patel
would not be in that day.
The investigator attended at the
pharmacy the following day. Again,
only a non-pharmacist employee was
on duty in the dispensary area. After
identifying himself as an investigator
with the College, the investigator was
advised that Mr. Patel was upstairs
in the washroom. The investigator
34
found Mr. Patel in a room on the
second floor with a patient. Mr. Patel
was in the process of administering a
treatment unrelated to the practice of
pharmacy.
The investigator discussed the
College’s concerns about the nonsupervision of the pharmacy with
Mr. Patel. Mr. Patel claimed that it
was his understanding that the entire
building was part of the accredited
premises. As noted on page 36, Mr.
Patel had previously been counselled
by the Complaints Committee of the
College regarding supervision of the
pharmacy and the parameters of the
licensed pharmacy.
Mr. Patel told the investigator that
the two relief pharmacists he customarily employed had not worked that
week, and that he was the scheduled
pharmacist for the entire week, including the previous day.
January 5 and 6, 2005
During the July 2006 site visit, and in
a subsequent e-mail, Mr. Patel confirmed to the investigator that he had
been out of the country from December 2004 until January 25, 2005.
The investigator retrieved pharmacy records associated with dispensing transactions processed on
January 5 and 6, 2005, including
computer generated hardcopy receipts. The majority of the hardcopy receipts were reprints, not contemporaneously generated originals. These hardcopy receipts were
endorsed with what Mr. Patel confirmed was his signature.
After the allegations of professional misconduct were referred to the
Discipline Committee, and just prior
to the pre-hearing conference, Mr.
Patel, through his counsel, advised
the College that, contrary to his previous statements, he had not been out
of the country on January 5 and 6,
2005, and that he had been present in
the pharmacy on both days. Mr. Patel
subsequently produced his passport,
which documented his departure
from Canada on January 14, 2005
and his return on January 24, 2005.
Mr. Patel also advised the College
that it had been necessary to reprint
the hardcopy receipts generated on
January 5 and 6, 2005, due to problems with his printer that rendered
the original records illegible. Mr. Patel had signed the reprinted hardcopy
receipts to replace the illegible original
records.
In light of the new information and
corroborating evidence provided by
Mr. Patel, the College, with leave of
the Panel, withdrew the allegations
with respect to operating the pharmacy without a pharmacist present
on January 5 and 6, 2005, and with
respect to falsifying records regarding
the transactions on those dates.
The Sale of Sildenafil
Without A Prescription
During his first attendance at the
pharmacy in July 2006, the investigator inquired about the availability
of a drug product called Magic Bullet. A person at the pharmacy who
described himself as Mr. Patel’s nonpharmacist partner told the investigator that they did not have Magic
Bullet, but that a similar product was
available. Mr. Patel’s partner then
provided the investigator with a blister package containing four tablets,
without a prescription, counselling, or
a receipt, in exchange for a cash payment of $40.
Subsequent laboratory testing
identified the tablets as containing
sildenafil, a Schedule I drug used
for treatment of erectile dysfunction, which may only be sold by prescription and dispensed by a licensed
pharmacist.
Mr. Patel stated that the individual who sold the tablets containing
the sildenafil to the investigator did so
without Mr. Patel’s knowledge or authorization. Mr. Patel also stated that
this individual, who had been responsible for natural health products at the
pharmacy, was no longer involved in
the operation of the pharmacy. Mr.
Patel did acknowledge that he was responsible, as owner and Designated
Manager, for the actions of staff at
the pharmacy.
Non-Licensed Natural
Health Products
During his site visits in July 2006, the
investigator observed that a number
of over-the-counter and herbal products were available in the pharmacy.
Many of these products were not
labelled in either English or French.
In September 2006, the investigator and a Health Canada official
attended at the pharmacy and determined that five of the over-thecounter and herbal products were not
approved for sale in Canada, since no
product licenses had been issued for
them by Health Canada, as required
under the Natural Health Products
Regulations to the Food and Drugs Act.
The Health Canada official removed
these products from the pharmacy.
Record and Recordkeeping
Discrepancies
During one of the July 2006 site visits, the investigator reviewed dispensing records, which revealed numerous
inadequacies in the pharmacy’s records and recordkeeping practices in
relation to the dispensing of prescription drugs, including narcotics.
Bundles containing more than
800 unsigned hardcopy receipts, associated with prescriptions that had
been processed in July 2006, were
discovered in a bin. These hardcopy
receipts were unsigned and contained no documentation in relation to any of the dispensing transactions. Mr. Patel was the scheduled pharmacist on duty throughout this period. The investigator’s review also disclosed records
processed on various dates documenting verbal authorizations that
had been reduced to writing by nonpharmacist staff members.
Deficiencies in the pharmacy’s
narcotic records and practices were
also noted. These included an inventory of controlled substances that had
been initiated but not completed, inadequate documenting of authorizations in relation to the dispensing of
narcotics, and unsigned hardcopy receipts for narcotics.
Mr. Patel stated that the bundles
of unsigned hard copies reflected the
pharmacy’s practice in relation to
dispensing to rest home facilities, and
that this practice had been discontinued. He also stated that the narcotic inventory had been interrupted
due to the conversion of the pharmacy’s computerized inventory program, and that since the conversion,
the pharmacy has conducted regular
inventories of its narcotics. Mr. Patel further stated that unsigned hardcopy receipts associated with the
dispensing of narcotics were the result of oversights on his part and on
the part of his staff. Finally, Mr. Patel stated that authorizations were
documented by technicians under his
supervision.
Admission of Professional
Misconduct
Mr. Patel admitted that he failed to
maintain a standard of practice of
the profession, failed to keep records
as required respecting his patients,
contravened the Drug and Pharmacies Regulation Act, the Food and
Drug Regulations, the Narcotic Control Regulations, the Benzodiazepines
and Other Targeted Substances Regulations and/or the Natural Health
Products Regulation, and that his conduct would reasonably be regarded
by members of the profession as disgraceful, dishonourable or unprofessional, in that he had:
• operated the pharmacy without a
registered pharmacist being physically present on July 28 and July 29,
2006,
• permitted the sale by or at the pharmacy of a product containing sildenafil without a prescription,
• made available for sale products
classified as natural health products
for which no product licenses had
been issued by Health Canada,
• allowed discrepancies in the processing of records created with
respect to dispensing and other
transactions,
• permitted pharmacy staff other
35
than a pharmacist to receive verbal
prescriptions, and
• failed to ensure that verbal directions to refill a prescription were
properly documented.
Prior Complaint
In February 2003, the Complaints
Committee considered a complaint
that the pharmacy had been left unsupervised because Mr. Patel was engaging in activities unrelated to the
practice of pharmacy on the second
floor of the building.
In its decision, the Complaints
Committee did not refer the matter
to the Discipline Committee, but did
remind Mr. Patel that he was legally
required by the Drug and Pharmacies Regulation Act to ensure that a
licensed pharmacist be on the pharmacy premises at all times during its
hours of operation. The Committee
further reminded Mr. Patel that the
accredited pharmacy was limited to
the main floor of the building.
The decision of the Complaints
Committee was communicated to
Mr. Patel in February 2004, prior to
the investigator’s visits to the pharmacy in July 2006.
Decision and Reasons
Mr. Patel’s misconduct in this case
included allowing operation of his accredited pharmacy without a pharmacist present, during which time
Mr. Patel was elsewhere in the building, in what was not an accredited
part of the pharmacy, engaged in activities unrelated to the practice of
pharmacy.
The Panel was frustrated by this
fact, given that Mr. Patel had already
36
been advised by the Complaints
Committee in 2004 not to engage
in such a practice. The Complaints
Committee had highlighted Mr. Patel’s obligations, and had specifically informed him that only the first
floor of the building was an accredited pharmacy. The Panel noted that
the Complaints Committee could
not have been more clear. Therefore,
there was no excuse for this continued misconduct by Mr. Patel.
The Panel was also greatly disturbed by other aspects of Mr. Patel’s misconduct, noting that it displayed a flagrant disregard for the
basics of pharmacy practice, and was
unacceptable for a Member of the
College. Public safety is paramount
in the practice of any health care
professional.
The Panel would have liked to
have seen suitable terms, conditions,
or limitations imposed on Mr. Patel’s
Certificate of Registration. However,
appreciating the need to accept Joint
Submissions on Penalty as proposed,
it did so.
Order
1. A reprimand,
2. Specified terms, conditions, or limitations on Mr. Patel’s Certificate
of Registration, requiring that he
complete successfully, at his own
expense, within six months of the
date of the Order, the following
courses and evaluations:
a) The Jurisprudence Seminar and
Evaluation offered by the College; and
b) Law Lesson 2 (Regulation of
Pharmacy Practice); and
c) Law Lesson 4 (Standards of
Practice); and
d) Law Lesson 7 (Professional Liability) from the Canadian Pharmacy Skills Program, offered
through the Leslie Dan Faculty
of Pharmacy at the University of
Toronto.
3. A suspension of Mr. Patel’s Certificate of Registration for a period of
four months, with two months of
the suspension to be remitted, on
condition that he complete the remedial training exercises specified
above.
4. Costs to the College in the amount
of $6,500.
Reprimand
The Panel was, in a word, disappointed in Mr. Patel. He was clearly an able person who understood his
obligations. Nevertheless, he had betrayed the public’s trust.
The law is very clear that an open
pharmacy must be supervised by a licensed pharmacist. Mr. Patel’s presence in his second-floor office and
treatment centre did not satisfy this
requirement. This had been conveyed
to him by the Complaints Committee
in February 2004, yet he still practised pharmacy and attempted to
run his pharmacy from premises that
were not accredited by the College.
Therefore, the Panel was disappointed that Mr. Patel was appearing before it on such charges.
The public had been put at risk
when patients purchased non-approved natural health products from
Mr. Patel’s pharmacy and bought prescription products without prescriptions from unsupervised members of
his staff. Mr. Patel’s recordkeeping
discrepancies and lack of attention to
detail added to this risk.
Mr. Patel’s misconduct harmed the
trust the public placed in him and in all
pharmacists.
One of the goals of a disciplinary
hearing is, rightly, to instil and reinforce public confidence that the
College is fulfilling its mandate to
protect and serve the public. The
public wants reassurance that the
College has exemplary pharmacists working in Ontario. It was the
Panel’s hope that the prescribed remedial work, and the reflective period of suspension, would help Mr.
Patel to be a better pharmacist in the
future, and that he would not appear before the Discipline Committee again.
As a cautionary note, the Panel felt
it must warn Mr. Patel that if he were
to appear again on similar charges, it
is conceivable that terms, conditions,
or limitations might be placed on his
Certificate of Registration, which
could include a prohibition from owning, operating, or being a Designated
Manager of any pharmacy.
Case 2
Unauthorized self-dispensing of
narcotic preparation
Member: Howard Weinmaster
Pharmacy: Shoppers Drug Mart,
Kapuskasing
Hearing date: June 23, 2008
Facts
The College received information
regarding a series of narcotic self-
dispensing transactions by Mr. Weinmaster between May 2004 and January 2006. In August 2006, the Executive Committee referred specified
allegations of professional misconduct
against Mr. Weinmaster to the Discipline Committee. In particular, it was
alleged that while employed and on
duty at Shoppers Drug Mart in Kapuskasing as a dispensing pharmacist,
Mr. Weinmaster dispensed Fiorinal® C ½ to himself in various quantities and without authorization on 12
occasions.
After being served with a Notice of Hearing, Mr. Weinmaster retained counsel to represent him. A
pre-hearing conference convened
in February 2007 did not result in a
resolution of the allegations, and further inquiries and discussion ensued.
However, in October 2007, counsel for the Member notified the College that she had removed herself
from the record, due to Mr. Weinmaster’s failure to provide her with
instructions.
The College’s prosecutor attempted to contact Mr. Weinmaster
directly in order to proceed with the
case, but Mr. Weinmaster’s contact
information on file with the College
was no longer correct. During the
course of those attempts, the College
learned that Mr. Weinmaster had unexpectedly and abruptly moved from
his last known residential address in
Kapuskasing, and that he had left his
last known place of employment in
that region.
Further inquiries revealed that Mr.
Weinmaster had relocated to Yorkton, Saskatchewan, where he was
residing with an adult son. When
contacted by the College’s prosecutor, Mr. Weinmaster advised that due
to health reasons, he was resigning his
membership with the College.
Resignation, Undertaking,
and Stay of Proceedings
Mr. Weinmaster signed an agreement to permanently resign from the
College and has undertaken never
to apply for membership in the College in the future, or to own any
pharmacy.
In the circumstances, the College
and Mr. Weinmaster jointly submitted that the public interest can be
fully protected without the Discipline
Committee making any findings of
professional misconduct against Mr.
Weinmaster. The Discipline Committee agreed, and, in light of Mr. Weinmaster’s resignation from the College
and his undertaking, made an order
staying the allegations of professional
misconduct against Mr. Weinmaster.
Case 3
Labelling errors, failure to keep
records, misidentified or inadequately
identified drugs
Member: Bhusmang Mehta
Pharmacy: King West Pharmacy,
Hamilton
Hearing Date: June 26, 2008
Facts
Mr. Mehta was the sole owner and
Designated Manager of a pharmacy
which he sold to Abadir Nasr in August
2004. Following the sale, Mr. Mehta
continued to work at the pharmacy on
37
a part-time basis, but was not involved
in the purchase of drug products for the
pharmacy.
Unapproved and
Counterfeit Norvasc™
In March 2005, a patient who regularly
had prescriptions for Norvasc™ filled
at the pharmacy became concerned
that the Norvasc™ looked significantly
different from the Norvasc™ that had
previously been dispensed to her. She
raised her concerns with the pharmacist
at a different pharmacy, and presented
two vials of Norvasc™ to that pharmacist, both of which she had obtained
from the pharmacy where Mr. Mehta
worked pursuant to prescriptions.
That pharmacist forwarded the
vials to Pfizer Inc., the manufacturer
of Norvasc™. Pfizer carried out an
analysis of the drug products in May
2005 which revealed that the tablets
in one of the vials were manufactured
by Pfizer for sale in Turkey, but were
not approved for sale in Canada (“unapproved Norvasc™”). The tablets in
the other vial contained little or none
of the active ingredient in Norvasc™
(“counterfeit Norvasc™”).
Pfizer contacted the RCMP about
the Norvasc™ dispensed by the pharmacy in May 2005. Pfizer also arranged for a private investigator to attend at the pharmacy in May 2005,
posing as the patient, to fill a prescription for Norvasc™. The drug product
dispensed was then analyzed by Pfizer,
and was determined to be counterfeit
Norvasc™.
The RCMP and the College, along
with other federal and provincial agencies, attended at the pharmacy in June
2005 to conduct an unannounced
38
search of the premises. In the course of
the search, the RCMP seized all pharmacy records and drug products related to the purchase and sale of Norvasc™. The College investigators generated computer reports for all transactions at the pharmacy involving Norvasc™ for the 100 days prior to the date
of the search.
On the day of the search, the College seized the pharmacy’s entire inventory of prescription drugs. The pharmacy remained open following the day
of the search, with new inventory.
On the day of the search, the RCMP
identified two patients for whom the
pharmacy had previously filled prescriptions for Norvasc™. Samples of the
tablets dispensed by the pharmacy to
these patients were obtained from the
patients and analyzed by both Pfizer
and Health Canada. Some of the tablets were unapproved Norvasc™ and
some were counterfeit Norvasc™.
Subsequent to the search in June
2005, the RCMP contacted other patients who had filled prescriptions for
Norvasc™ at the pharmacy. These patients provided samples of the medications that had been dispensed to them
by the pharmacy as Norvasc™, and
these products were analyzed by Pfizer or the RCMP Forensic Laboratory
Services. Of 61 samples of Norvasc™
dispensed by the pharmacy, 8 samples
contained Norvasc™ approved for sale
in Canada, 9 samples contained unapproved Norvasc™, 32 samples contained counterfeit Norvasc™, and 12
samples contained a mixture of Norvasc™ approved for sale in Canada
and either counterfeit or unapproved
Norvasc™.
The Coroner’s Office reviewed the
deaths of 11 patients to whom Norvasc™ may have been dispensed by the
pharmacy, and the Coroner determined that counterfeit or unapproved
Norvasc™ could not have played any
role in 7 of the deaths. The evidence
with respect to the other 4 cases was
inconclusive and the manner of death
was noted as “undetermined”, with
the medical cause of death given as
“possible unauthorized medication
substitution”.
The unapproved Norvasc™ and
counterfeit Norvasc™ were drug products purchased by Mr. Nasr. Mr. Mehta stated that he was not involved in
any way with these drug purchases,
and there is no evidence to suggest that
he was.
Mr. Mehta was the dispensing pharmacist in respect of approximately a
dozen transactions involving counterfeit or unapproved Norvasc™ between
January 27, 2005, and May 5, 2005.
Mr. Mehta stated that when he reviewed the medication he dispensed
on January 27, 2005, he noticed differences in the appearance of what was
ultimately identified as unapproved
Norvasc™. In particular, he noted the
change in the shape of the drug product (round rather than octagonal). He
asked the pharmacy technician about
the change of appearance. She told
him that she had discussed the issue
with Mr. Nasr, the owner of the pharmacy, and that the change had been
authorized by Pfizer.
After receiving this information, Mr.
Mehta verified that the DIN (drug identification number) on the stock bottle corresponded with the DIN on the hardcopy
receipt. He then signed the prescription
and dispensed the medication.
Mr. Mehta also recalled, during this
incident, a previous instance, in 2004,
of a slight colour variation in another
medication, when Pfizer had encountered difficulty sourcing the raw material for it. In the circumstances, Mr.
Mehta accepted and relied upon the
explanation provided by the pharmacy
technician. He had never before experienced a problem with unapproved
or counterfeit drug products and,
therefore, did not perceive a need to
make any further inquiries.
The balance of the dozen dispensing transactions involved counterfeit
Norvasc™ that Mr. Mehta subsequently dispensed to patients. Unlike
the unapproved Norvasc™ which bore
certain subtle but discernible physical
anomalies, the counterfeit Norvasc™
tablets were very similar in appearance
to authentic Norvasc™ tablets and,
thus, virtually impossible to detect.
Mr. Mehta stated that he did not
note any discrepancies regarding the
drug product subsequently identified
as counterfeit Norvasc™ until the investigations by the RCMP and the
College.
On the basis of his experience with
this matter, Mr. Mehta now recognizes
that unapproved and counterfeit drug
products can be and, indeed, have been
introduced into the drug supply system in Canada. Mr. Mehta recognizes that a reasonably prudent pharmacist should now make his or her own
independent inquiries upon noticing a
change in a drug product.
Mr. Mehta stated, and the College
accepted, that he did not knowingly
dispense any drug product identified
as Norvasc™ that was counterfeit or
not approved for sale in Canada.
Abadir Nasr Discipline
Committee Decision
Mr. Nasr’s conduct in relation to the
purchase and dispensing of counterfeit
and unapproved Norvasc™, inter alia,
was the subject of a hearing before the
Discipline Committee. On September 6, 2007, Mr. Nasr was found guilty
of professional misconduct in his capacity as a dispensing pharmacist and as
the owner and designated manager of
the pharmacy. By majority decision,
the Discipline Committee accepted a
Joint Submission for a penalty Order
comprised of a reprimand, suspension
of his Certificate of Registration for
12 months, remedial training, restrictions on ownership or management of
a pharmacy, and costs.
Additional Practice Issues
The College’s investigation continued
after the initial search of the pharmacy
with the RCMP in June 2005. The
review of pharmacy records and drug
products seized from the pharmacy revealed other problems in the practice
of pharmacy by Mr. Mehta and in the
operation of the pharmacy.
Labelling Discrepancies
The College investigators checked prescriptions that had been prepared and
were waiting to be picked up by patients when they searched the pharmacy in June 2005. In a number of
cases, one generic drug product was
named on the label, but a different
generic drug product was found in the
vial.
After the RCMP investigation
was publicized, the College was contacted by a number of Hamilton pharmacists who reported that patients
were turning in medications, other
than Norvasc™, that the pharmacy
had dispensed. The College’s subsequent comparative review of these
medications and their labelled vials revealed additional labelling errors in relation to medications Mr. Mehta had
dispensed.
Recordkeeping and Billing Issues
College investigators reviewed the
records of various dispensing transactions against the claims submitted
to insurers for those transactions. In
many cases, the generic drug product
identified in the claim for the insurers
did not correspond to the generic drug
that was actually dispensed to the patients. Handwritten notations on the
hardcopy receipts ostensibly identified
the generic drug product actually dispensed. There was no financial advantage to submitting the claim for a different drug product than the product
actually dispensed, but the result was
claim records that did not accurately
reflect what drug products were actually dispensed to patients.
Mr. Mehta stated, and the College
accepted, that the decision to consolidate different generic drug products
was made by Mr. Nasr, as owner of the
pharmacy. Mr. Mehta advised against
this practice but his advice was not
heeded. However, Mr. Mehta admits
that he acquiesced in the practice of
dispensing mixed generic drug products
when he was the pharmacist responsible for filling patients’ prescriptions.
Mr. Mehta acknowledges that it was
improper to dispense one generic brand
of a drug product to the patient while
submitting a claim to the insurer identifying a different generic drug product,
39
even if the price of the products and the
amounts of the claims were the same.
The mixing of the drug products and
the inaccurate records would make it
impossible to determine exactly what
drug product was dispensed to which
patient. The practice would make it
impossible, for example, to implement
a drug recall or warning for any of the
prescription drug products.
Acknowledgement of
Professional Misconduct
Mr. Mehta admitted that he committed acts of professional misconduct in
that there were discrepancies in the
dispensing, labelling, billing and/or recordkeeping of interchangeable drug
products that he dispensed, such that:
• he failed to maintain a standard of
practice of the profession,
• he signed or issued, in his professional capacity, documents that he knew
contained false or misleading statements, and
• he engaged in conduct that would reasonably be regarded by members of
the profession as unprofessional.
The College withdrew, with leave of
the Discipline Committee, the allegations of professional misconduct in connection with the purchasing, stocking,
or dispensing of Norvasc™, and the allegations that Mr. Mehta’s conduct was
disgraceful or dishonourable.
Reasons for Penalty
The Panel carefully considered the
parties’ Joint Submission on Penalty, and considered its reasonableness.
The Panel was concerned about two
specific issues: first, the appropriateness of the penalty as it relates to Mr.
Mehta’s specific circumstances, and
40
second, the impact of this case on future cases.
Regarding Mr. Mehta, the Panel
was mindful of the extraordinary and
unique circumstances of this case. The
penalty proposed took into account Mr.
Mehta’s previously unblemished record, his conduct subsequent to the incidents, and the public humiliation and
shame the he has endured as a result
of widespread media coverage of this
matter ever since the original RCMP
raid.
For approximately 12 years, Mr. Mehta had owned, operated, and managed the pharmacy in a manner consistent with high standards of practice, as confirmed by College inspection reports. Unfortunately, the only
time there was a lapse in Mr. Mehta’s
professional conduct was after he had
sold the pharmacy to Mr. Nasr and became his employee.
The Panel was mindful of the publicity this matter had attracted, which
had painted Mr. Mehta with the same
brush as Mr. Nasr. So that it is clear,
the Panel confirmed in the Decision
that Mr. Mehta was not involved with
Mr. Nasr’s misconduct relating to Norvasc™. Rather, the findings of professional misconduct regarding Mr. Mehta
stemmed from non-Norvasc™ issues,
and his complacency in following the
dictates of Mr. Nasr, his employer at
the time.
This was a unique case, with no
precedents. The Panel found that the
proposed penalty was not unreasonable, considering all the circumstances,
and that it met the objectives of protecting the public interest and the profession, while also addressing Mr. Mehta’s situation.
The Panel was concerned that the
College membership might misunderstand the decision. This case was
about the fact that while he owned
and managed the pharmacy, Mr. Mehta practised to a high standard, but
having sold the pharmacy to Mr. Nasr
and become his employee, Mr. Mehta
did not maintain those high standards.
Although Mr. Mehta was uncomfortable with Mr. Nasr’s practice with regard to interchangeable drugs, and apparently disagreed with Mr. Nasr on
proper practice in this area, he ultimately acquiesced and practised in a way
that brought him before the Discipline
Committee.
The Panel wanted to send a message to the profession that following
the orders of one’s employer is not an
acceptable defence against allegations
of professional misconduct.
Order
1. A reprimand.
2. Terms, conditions, or limitations on
Mr. Mehta’s Certificate of Registration, requiring him to complete
successfully, at his own expense,
within 6 months of the date of this
Order, the following courses and
evaluations:
(a) The Jurisprudence seminar and
evaluation offered by the College; and
(b) L aw Lesson 2 (Regulation of
Pharmacy Practice) from the
Canadian Pharmacy Skills Program, offered through the Leslie
Dan Faculty of Pharmacy at the
University of Toronto.
3. A suspension of his Certificate of
Registration for a period of one
month, the suspension to be remitted
on condition that he complete the
above-noted remedial training.
4.Costs to the College in the amount
of $2,000.
Reprimand
While the circumstances that brought
Mr. Mehta before the Panel might be
unfortunate, the Panel did not feel that
all of the responsibility lay elsewhere.
The Panel was very disappointed
that someone with Mr. Mehta’s experience would have failed to realize
that his responsibilities lay beyond simply documenting discrepancies on the
hardcopy receipts or verbally advising
his patients of changes to their medications. By not taking further action,
such as being more firm with his employer, or even reporting the improper
dispensing practices in which he found
himself involved, Mr. Mehta placed
the health and safety of his patients at
risk. That is not acceptable. Mr. Mehta
should never be satisfied with anything
less than the profession’s Standards of
Practice.
The Panel believed that Mr. Mehta
had learned from this unfortunate experience and trusted that he would not
appear before the Discipline Committee again.
Case 4
Criminal conviction/fraud over $5,000
Member: Godwin Uchenna Ogowa
Hearing date: May 21, 2008
Decision issued: June 9, 2008
Facts
Mr. Ogowa admitted the specified
allegations of professional misconduct, namely that he had been found
guilty of criminal charges that were
relevant to his suitability to practice
the profession of pharmacy, and that
he had failed to report those charges and findings of guilt to the College, and that he had thereby engaged in conduct or performed an
act relevant to the practice of pharmacy that, having regard to all the
circumstances, would reasonably be
regarded by members as disgraceful,
dishonourable or unprofessional.
More specifically, Mr. Ogowa had
been convicted of fraud exceeding
$5,000, contrary to section 380(1)
(a) of the Criminal Code of Canada
on or about March 23, 2007, with
respect to false claims in the approximate amount of $145,000 that
he submitted to the Ontario Drug
Benefit Plan (the “ODB”) from a
pharmacy he owned from January to December 2001. He no longer
owns or manages any pharmacy.
In the criminal matter, Mr. Ogowa
received a sentence requiring full
restitution of the amount, and imposing a conditional sentence of
18 months, a period of community
service, and a period of probation.
Mr. Ogowa had paid approximately
$51,000 of the restitution on the date
of sentencing. He was paying the remainder in monthly instalments, and
still had approximately seven to ten
such payments to make.
The facts were put into evidence
by way of the transcript of the criminal proceedings. Patients eligible for
the Ontario Drug Benefit attended
at Mr. Ogowa’s pharmacy with prescriptions for medications they did
not require. Mr. Ogowa would bill
the prescriptions through to the
ODB, but instead of dispensing the
medication he would give the patient
either cash or other merchandise
from the pharmacy.
The judge at the criminal trial
noted that this was a deliberate scam
conducted over a period of one year,
and that Mr. Ogowa as a professional had breached a position of trust.
In effect, he had also stolen public monies and had deprived people
who were truly in need of ODB plan
assistance.
The Panel found the Member to
be guilty of professional misconduct.
Submissions on Penalty
The hearing was contested with respect to the appropriate penalty.
The College presented a number of past decisions of the Discipline
Committee in cases similar to this
one. The penalties ordered in those
cases ranged from a suspension of
one year, to revocation of the member’s Certificate of Registration. The
College suggested that the penalty
imposed had to send a deterrent message to other members of the profession, and a strong message that protection of the public was the College’s
primary interest.
Counsel for Mr. Ogowa proposed that his Certificate of Registration should not be revoked, but
rather that a lengthy suspension
should be imposed. It was submitted that Mr. Ogowa was a good person, a good pharmacist, and a pillar of the community, and that many
dependents relied on him financially
and spiritually. It was suggested that
41
any suspension imposed should not
take effect until after Mr. Ogowa had
completed paying the restitution ordered at his criminal trial.
Decision and Reasons
In the Panel’s view, of the cases referred to by the College, the one
most similar to this case was that of
Felix Ayigbe (see November/December 2002 Pharmacy Connection, also available online). That
case involved irregular billings in the
amount of $196,000. The Member
had a prior discipline finding, and received (among other things) a oneyear suspension of his Certificate of
Registration.
The Panel noted that Mr. Ogowa
had apparently been approached a
number of times about a fraudulent
billing scheme. Ultimately, he succumbed to greed and participated in
such a scheme, but he accepted responsibility for his actions, and did not
blame or accuse others.
In the criminal court Mr. Ogowa
had waived his preliminary hearing,
and both there and before the College he had pleaded guilty, thus saving all the parties time and effort. Mr.
Ogowa also personally apologized
and expressed his remorse to the
Panel. The Panel felt that this showed
his desire to make right what was
wrong, and to become again a good
and productive member of society.
The Panel stated that there was
no evidence of any deficiencies in Mr.
Ogowa’s clinical skills and abilities as
a dispensing pharmacist. Therefore,
no remediation related to those skills
appeared to be necessary. However,
the Panel was alarmed by the fact
42
that Mr. Ogowa’s participation in the
fraudulent scheme seemed to have
started just after he had received a
reprimand and a one-month suspension in an earlier, unrelated discipline
matter. Therefore, the Panel felt that
remedial work regarding ethics and
the regulation of the profession would
help serve the goals of education of
Mr. Ogowa and ensure the protection
of the public.
The Panel noted that, at a point
late in his career, Mr. Ogowa found
himself working long hours at two
pharmacies in order to pay restitution
in his criminal matter. The Panel felt
that imposing a further financial sanction would be a suitable deterrent.
However, the Panel also noted
that if a suspension of Mr. Ogowa’s
Certificate of Registration were to
take effect immediately, he would be
unable to pay the criminal restitution
and make good the harm he had done
to the ODB. Moreover, he would perhaps be jailed, and in that event would
be unable to pay any costs and fine
ordered by the Panel.
Order
1. A reprimand;
2.Eight months’ suspension of Mr.
Ogowa’s Certificate of Registration, with two months of that suspension to be remitted on condition that he complete remediation
listed below;
3.Terms, conditions or limitations on
Mr. Ogowa’s Certificate of Registration requiring him to complete
successfully, at his own expense,
and within 18 months of the date
of the Order, the following courses
and evaluations:
• Law Lesson 2 (Regulation of
Pharmacy Practice),
• Law Lesson 7 (Professional Liability), from the Canadian Pharmacy Skills Program offered
through the Leslie Dan Faculty
of Pharmacy at the University of
Toronto, and
• The Jurisprudence seminar offered by the Ontario College of
Pharmacists;
4.Additional terms, conditions or
limitations on Mr. Ogowa’s Certificate of Registration for a period of
five years:
• Prohibiting him from owning a
pharmacy;
• Prohibiting him for being the
Designated Manager of a
pharmacy;
• Requiring him to notify the College in writing of any employment
in a pharmacy for five or more
days;
• Requiring him to ensure that his
employers confirm in writing that
they have received and reviewed
a copy of the Panel’s decision;
• Requiring him to be paid only on
hourly or weekly rates, and not
on any incentive for the value of
volume of prescription sales;
• Requiring him to ensure that his
employers confirm to the College
the nature of his remuneration,
and that they agree to review his
billings on a quarterly basis and
report any irregularities to the
College.
5.Mr. Ogowa to pay a fine of $10,000
to the Ministry of Finance;
6.Mr. Ogowa to pay costs of $10,000
to the College.
Dissent (in part)
Reprimand
One public member of the Discipline
Panel did not believe that this case
could be distinguished or meaningfully differentiated from the Ayigbe
case, where a suspension of one
year had been ordered. Mr. Ogowa’s
misconduct was serious, and it had
taken place immediately after he
was found guilty of professional misconduct by the Discipline Committee on another matter. While agreeing with the rest of the elements of
the Panel’s penalty order, this Panel
member felt that a longer period
of suspension would have been appropriate, and further, agreed with
Mr. Ogowa’s counsel that remedial
coursework was not called for. Since
these views were not held by the
majority of the Panel members, the
Order above was the Order of the
Panel.
The reprimand was administered on
July 21, 2008. The Panel took the
charges against Mr. Ogowa very seriously, and noted that it is not for
the Panel to allow the courts to deal
wholly with members of the College
who commit criminal offences. Rather, the Panel must support the courts
and mete out decisions that send a
message to the public, the College,
and its members. In this case, the
message to be sent is that fraudulent
activity, no matter the cause or motivating factor, will not be tolerated.
The Panel was angered by Mr.
Ogowa’s fraudulent activities. The
Panel appreciated the fact that Mr.
Ogowa owned up to his actions.
However, the Panel was bothered by
the facts that the fraudulent activities
were perpetrated over a period of at
least one year, and that Mr. Ogowa
did not properly notify the College of
the charges against him even when
specifically asked to do so.
The Panel noted that it expects all
members of the profession to uphold
the high standards the public expects
of pharmacists. Mr. Ogowa’s willingness to participate in fraudulent activity detracts from this ideal, and his
actions have left a scar on the profession. In spite of all the good work that
Mr. Ogowa may do to try to hide the
scar, it can never be fully removed or
erased.
The Panel was aware that Mr.
Ogowa’s fraudulent activity has had
a detrimental impact on his personal
life. The Panel indicated that it believes the criminal, legal and professional sanctions and experience have
changed Mr. Ogowa, and the Panel
hoped that the sanctions serve to
make Mr. Ogowa the best pharmacist
he can possibly be.
43
44
focus on error prevention
Ian Stewart, R.Ph., B.Sc.Phm
Toronto Community Pharmacist
Administering drugs to infants
T
o ensure patient safety, the right drug must be given
to the right patient at the right dose, by the right
route at the right time. This is particularly important when administering drugs to infants due to their smaller
body mass and incomplete development of their body organs
and defense systems. Their ability to metabolize and excrete
medications is therefore limited. Hence, pediatric patients
are at a greater risk of experiencing an adverse drug event.
Case:
A newborn was prescribed trimethoprim for urinary tract
infection prophylaxis at a dose of 7 mg once daily. A 10 mg/
ml oral suspension was prepared correctly and labelled with
the directions to give 0.7 ml once daily. The pharmacist
counseled the child’s mother, and a ten-milliliter oral syringe
was given to administer the dose.
On arriving home, the mother gave seven milliliters of
the suspension to the child instead of the prescribed 0.7 ml.
The tenfold error in dosage continued for a few days until
the child was taken to the prescribing physician for a follow
up visit. The error was then detected and the dispensing
pharmacy contacted to discuss the occurrence. Though the
child experienced adverse effects as a result of the overdose,
no long term adverse effects occurred.
• There was no marking on the syringe to indicated exactly 0.7 ml.
• The seven-milliliter mark on the syringe is indicated as “7”
and not 7 ml. This may have contributed to the parent’s
misunderstanding of the dose to be administered.
• The pharmacy only stocks the ten-milliliter oral syringe.
Recommendations
• When counseling patients, clearly communicate the dose
to be administered. This is especially critical when unusually small doses are being given to pediatric patients.
• Demonstrate the volume of medication to be administered by pulling the plunger of the oral syringe back to the
required mark.
• Clearly indicate on the oral syringe the exact volume to be
given. The product Mark-A-Dose ™ (supplied by Pharmasystems) is a clear pressure sensitive adhesive label,
which can be attached to the oral syringe to indicate the
correct dosage.
• Consider stocking the one, three, five and ten milliliter oral
syringes. Provide the most appropriate size based on the
volume to be administered.
• If providing a syringe cap, caution parents about the potential choking hazard in small children if the cap is inappropriately discarded.
Possible Contributing Factors
• Miscommunication between the pharmacist and mother
regarding the dose to be given.
• The pharmacist provided a ten-milliliter oral syringe. A
smaller size oral syringe may be more appropriate for a
dose of only 0.7 ml.
45
CE resources
Visit the College’s website: www.ocpinfo.com for a complete listing of upcoming events and/or available
resources. A number of the programs listed below are also suitable for pharmacy technicians.
GTA
September 2008
Supportive Care Issues in
Oncology (part 1&11) University of Toronto (UofT)
maria.bystrin@utoronto.ca
September 26, 2008
Paediatrics for Pharmacists
Conference
The Hospital for Sick Children
sara.mcdermott@sickkids.ca
416-813-6703
October 1-3, 2008
Thrombosis Management for
Pharmacists - UofT
October 2008
Geriatric Pharmacy Practice
conference - UofT
October 2-5, 2008 (COPD Oct 2)
Certified Asthma Educator (CAE)
/Certified Respiratory Educator
(CRE) and COPD Patient Care
Preparation Course
Contact: Penny Young
pyoung@dirc.ca
416-441-0788 ext. 2209
October 3-4, 2008
Pediatric Hemostasis &
Thrombosis Update
Contact: Faculty of Medicine University of Toronto
416 978-2719/1-888-512-8173
help-PAE0803@cmetoronto.ca
www.cme.utoronto.ca
46
October 3-5, 2008
Diabetes Patient Care - Level 2
Certificate Program
Ontario Pharmacists’ Association
pyoung@dirc.ca
416-441-0788 ext. 2209
October 6 – 10
Comprehensive Course on Smoking Cessation: Essential Skills and
Strategies (French version)
CAMH
Contact: Jean-Francois Crepault
(416) 535-8501 x7433
jf_crepault@camh.net
October 15, 2008
Tri-professional Conference:
a call for collaboration
Ontario pharmacists, physicians and
nurse collaborators
The Fairmont Royal York, Toronto
https://www.exporeg.com/
triprofessional/
October 31-Nov 2, (Part 1);
November 21-23 (Part 2), 2008
Certified Geriatric Pharmacist
Preparation Course
Ontario Pharmacists’ Association
pyoung@dirc.ca
416-441-0788 ext. 2209
Nov 7, 2008
Root Cause Analysis (RCA)
Workshop for Pharmacists
ISMP Canada
Contact: Certina Ho
cho@ismp-canada.org
416-733-3131 x 233
www.ismp-canada.org/rca.htm
November 7, 2008
Herbs in the Media - What works
and what doesn’t - UofT
Contact: maria.bystrin@utoronto.ca
November 7-9, 2008
The 5th Annual Canadian
Interdisciplinary Network for
Complementary
and Alternative Medicine Research (IN-CAM) Symposium
- UofT
Contact: maria.bystrin@utoronto.ca
November 15, 2008
Canadian Society of Hospital
Pharmacists Ontario Branch AGM
- UofT
Contact: Susan Korporal
skorporal@cshp.ca
ONTARIO
September 18 – 20
OPA Conference 2008
Niagara Falls, ON
www.opatoday.com
October 21, 2008
Medications in Pregnancy and
Breastfeeding
3rd Annual Ivey Symposium
St.Joseph’s Hospital, London,
Ontario
Contact: Maude Rouleau
iveytox@uwo.ca
519-661-3128
CANADA
September 11-12, 2008
The Many Faces of Palliative Care
Winnipeg, Mannitoba
Hospice and Palliative Care
Contact: Andrea Firth
204 889 8525 ext 225
laws & regulations
Drug and Pharmacies Regulation Act (DPRA) * s
Amended June 4, 2008
Regulations to the DPRA:
DPRA R.R.O. 1990, Regulation 545 – Child Resistant Packages
DPRA Ontario Regulation 297/96 Amended to O.Reg. 173/08 – General
DPRA R.R.O. 1990, Regulation 551 Amended to O.Reg. 172/08 – General
Drug Schedules **
Summary of Laws Governing Prescription Requirements,
Transfers, Refills, Prescription Drug Ordering and Records
June 2007 OCP
Canada’s National Drug Scheduling System –
August 27, 2008 NAPRA (or later)
Regulated Health Professions Act (RHPA) * s
Amended 2007
Regulations to the RHPA:
Ontario Regulation 39/02 -Certificates of Authorization Amended to
O.Reg. 666/05
Ontario Regulation 107/96 – Controlled Acts Amended to O.Reg. 296/04
Ontario Regulation 59/94 – Funding for Therapy or
Counseling for Patients Sexually Abused by Members
Pharmacy Act (PA) & Regulations * s
Amended 2007
Regulations to the PA:
Ontario Regulation 202/94 Amended to O.Reg. 270/04 – General
Ontario Regulation 681/93 Amended to O.Reg.
122/97 – Professional Misconduct
Standards of Practice s
Standards of Practice, January 1, 2003 OCP
Standards of Practice for Pharmacy Managers, July 1, 2005
Drug Interchangeability and Dispensing
Fee Act (DIDFA) & Regulations * s
Amended 2007 Regulations to the DIDFA:
R.R.O. 1990 Regulation 935 Amended to O.Reg. 321/07 – General
R.R.O. 1990 Regulation 936 Amended to O.Reg. 205/96 – Notice to Patients
Food and Drugs Act (FDA) & Regulations ** '
Updated as of December 31, 2006
Amendment 1478 & 1491 – Addition of two medicinal ingredients
to Part I of Schedule F. Reg. SOR/2007-224, Oct 25/07
Amendment 1476, 1502, 1511 and 1512 –
Addition of nine medicinal ingredients to Part I of
Schedule F. Reg SOR/2007-234, Oct 25/07
Regulations Amending the Food and Drug Regulations (Project 1551
- Lanthanum salts) (February 7, 2008)
Controlled Drugs and Substances Act (CDSA) **
Current as of July 27, 2008
Regulations to the Controlled Drugs
and Substances Act (CDSA) **
All regulations updated August 13, 2008
Benzodiazepines & Other Targeted Substances Regulations
Marihuana Medical Access Regulations
Precursor Control Regulations
Regulations Exempting Certain Precursors and
Controlled Substances from the Application of
the Controlled Drugs and Substances Act
Narcotic Control Regulations **
OCP By-Laws
By-Law No. 1 – December 2007 s
Schedule A - Code of Ethics for Members of the
Ontario College of Pharmacists - December 2006
Schedule B - “Code of Conduct” and Procedures for
Council and Committee Members - December 2006
Schedule C - Member Fees - Effective January 1, 2007
Schedule D - Pharmacy Fees - Effective January 1, 2007
Schedule E – Certificate of Authorization – Jan. 2005
Schedule F - Privacy Code - Dec. 2003
Reference s
OCP Required Reference Guide for Pharmacies
in Ontario, August, 2008
Ontario Drug Benefit Act (ODBA) & Regulations * s
Amended 2007
Regulations to the ODBA:
Ontario Regulation 201/96 Amended to O.Reg. 264/18 – General
* Information available at Publications Ontario (416) 326-5300 or 1-800-668-9938 www.e-laws.gov.on.ca
** Information available at www.napra.org
' Information available at Federal Publications Inc. Ottawa: 1-888-4FEDPUB (1-888-433-3782)
Toronto: Tel: (416) 860-1611 • Fax: (416) 860-1608 • e-mail: info@fedpubs.com
s Information available at www.ocpinfo.com
47
September/October 2008 • Volume 15, Number 5

PC September/October 2008 - Ontario College of Pharmacists

Transcription

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