July ⢠August 2003 - Ontario College of Pharmacists
July ⢠August 2003 - Ontario College of Pharmacists
July ⢠August 2003 - Ontario College of Pharmacists
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DISCIPLINE<br />
DISCIPLINE<br />
CASE 2<br />
Failure to Take Appropriate Care When Dispensing<br />
Coumadin ® to a Patient; Failure to Obtain Requisite<br />
Authority to Dispense a Reduced <strong>of</strong> Quantity<br />
Member: Abdulkader Zalgaonker, Hespeler<br />
Hearing Date: February 27, <strong>2003</strong><br />
Mr. Zalgaonker was found to have:<br />
• Failed to maintain a standard <strong>of</strong> practice <strong>of</strong> the pr<strong>of</strong>ession<br />
• Contravened, while engaged in the practice <strong>of</strong> pharmacy,<br />
federal or provincial law or municipal by-law with respect<br />
to the distribution, sale or dispensing <strong>of</strong> a drug or mixture<br />
<strong>of</strong> drugs<br />
The following Agreed Statement <strong>of</strong> Fact formed the basis<br />
<strong>of</strong> Mr. Zalgaonker’s admission <strong>of</strong> pr<strong>of</strong>essional misconduct.<br />
Facts<br />
Mr. Zalgaonker is an owner, director, designated manager<br />
and dispensing pharmacist at his pharmacy.<br />
The patient was prescribed 250 Coumadin® 1mg<br />
tablets with directions to take two and one-half tablets<br />
once a day. Mr. Zalgaonker dispensed Coumadin® 5mg<br />
tablets in a container indicating that the contents were<br />
Coumadin® 1mg tablets. As a result, the patient<br />
consumed 12.5mgs <strong>of</strong> Coumadin® each day that she<br />
took the drug instead <strong>of</strong> the 2.5mgs that were<br />
prescribed. She suffered internal bleeding and was<br />
hospitalized for three days.<br />
In addition, the pharmacy records confirmed that the<br />
physician authorized three repeats <strong>of</strong> 250 Coumadin®. On<br />
some <strong>of</strong> these occasions, Mr. Zalgaonker reduced quantities<br />
without authority.<br />
Mr. Zalgaonker explained that the quantity <strong>of</strong> the<br />
prescription was reduced from 250 to 100 tablets to<br />
accommodate the limited personal budget <strong>of</strong> the patient<br />
and that he did not reduce the quantity for financial gain<br />
(which was marginal). Mr. Zalgaonker recognizes that the<br />
patient’s written authorization for the reduced quantities<br />
being dispensed would have been required in these<br />
circumstances.<br />
Reasons<br />
In accepting the Joint Submission on Penalty, the<br />
Committee considered that Mr. Zalgaonker has practised for<br />
20 years without any dispensing error complaints, and that<br />
since this incident Mr. Zalgaonker has developed new<br />
storage procedures for Coumadin® in the pharmacy by<br />
maintaining separately marked boxes for each strength and<br />
has revised his dispensing protocols to prevent future errors.<br />
The Committee also took into account that Mr.<br />
Zalgaonker was previously found guilty <strong>of</strong> pr<strong>of</strong>essional<br />
misconduct by the Discipline Committee in June, 1999 in<br />
connection with a conviction for income tax evasion by his<br />
pharmacy business for the years 1992, 1993, 1994 and<br />
1995, contrary to the Income Tax Act.<br />
Order<br />
1. A reprimand<br />
2. Specified terms, conditions and limitations on Mr.<br />
Zalgaonker’s Certification <strong>of</strong> Registration and in particular,<br />
that Mr. Zalgaonker complete successfully, at his<br />
own expense and within twelve months <strong>of</strong> the date <strong>of</strong> this<br />
order, the following:<br />
i) Courses <strong>of</strong>fered through the Canadian Pharmacy<br />
Skills Program: “Law Lesson 6 - Standards <strong>of</strong> Practice”<br />
and “Law Lesson 7 - Pr<strong>of</strong>essional Liability”<br />
ii) “Confronting Medication Errors” <strong>of</strong>fered by the<br />
<strong>Ontario</strong> <strong>Pharmacists</strong>’ Association, including<br />
“Module 1, Understanding the Issues and Dealing the<br />
Incidents” and “Module 2, Taking Action to Improve<br />
Patient Safety”<br />
3. A suspension for a period <strong>of</strong> two months; one month <strong>of</strong><br />
the suspension to be remitted on condition that Mr.<br />
Zalgaonker completes the remedial training workshops,<br />
courses and evaluations described in paragraph 2 above<br />
4. Costs to the <strong>College</strong> in the amount <strong>of</strong> $2,000<br />
Pharmacy Connection <strong>July</strong> • <strong>August</strong> <strong>2003</strong> 33