September/October 2002 - Ontario College of Pharmacists

DISCIPLINE
noted that she immediately contacted the patient’s family to
express her remorse and apologized to all concerned for this
unfortunate incident. Ms. Kearney further stated that she
co-operated fully with the investigation and appeared before
the Complaints Committee to explain changes she has
since made to her dispensing procedures to avoid a recurrence
of this type of error.
Reasons:
The member and the College provided a Joint Submission
on Penalty which the Committee carefully considered. It
noted that Ms. Kearney has no prior disciplinary history
before this College; she cooperated with the College
throughout this disciplinary process, and immediately
contacted the family to express her remorse. The
Committee also considered, however, that the conduct in
question was extremely serious. For this reason the
Committee concluded that the proposed penalty was fair
and reasonable and made the following Order:
Order:
1. A reprimand
2. A two-month suspension of the member’s Certificate of
Registration
3. A condition be placed on Ms. Kearney’s Certificate of
Registration that within one year from the date of this
Order she shall, at her own expense, take and successfully
complete the appropriate examinations for the
following two courses:
a) Jurisprudence seminar offered at the Ontario
College of Pharmacists
b) Advanced Professional Practice Labs of the
Canadian Pharmacy Skills II offered through the
Leslie Dan Faculty of Pharmacy at the University of
Toronto
In the event the member does not successfully complete the
above two courses within one year, her Certificate of
Registration will be suspended until such time as she
demonstrates to the College of Pharmacists that she has
successfully completed the above referenced courses.
Case 10
Dispensing Error
Member: Qamar Islam, Cornwall
Hearing Date: June 4, 2002
Mr. Islam was found to have failed to maintain a standard of
practice of the profession with respect to a dispensing error
on a prescription. The Committee accepted a plea of professional
misconduct by Mr. Islam and was provided with an
agreed statement of facts, which formed the basis of his plea.
Facts:
Mr. Islam was presented with a prescription for digoxin 0.4ml
of a 50mcg/ml solution po bid and for Lasix® 4mg po bid X 7
days for an infant who had just been released from hospital
following heart surgery. Instead of dispensing the digoxin as
0.4ml twice a day, Mr. Islam dispensed the prescription as
4ml twice a day, ten times the concentration of Digoxin. The
mistake was caught by the baby’s mother who confirmed the
correct dosage with the hospital. No patient harm occurred.
Reasons:
The member and the College submitted a Joint Submission
on Penalty which the Committee carefully considered,
taking into account that this was Mr. Islam’s first appearance
before the Discipline Committee, that he has shown
remorse for his actions; and that he undertook the appropriate
follow-up and acknowledged his mistake.
The Committee also took into account the seriousness of
this error and the possible consequences that may have
resulted, they noted that Mr. Islam and all pharmacists must
be aware that when errors occur they will be held responsible.
Order:
The Committee concluded that the proposed penalty was
fair and reasonable and made the following Order:
1. A reprimand
2. A one-month suspension of Mr. Islam’s Certificate of
Registration
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Pharmacy Connection September·October 2002