INSIDE - OCPInfo.com · 2014-01-09 · 9 BonnieHauser 10 GeraldCook 11 DavidMalian 12 PeterGdyczynski 13 DonaldStringer 14 StephenClement ... PracticeQ&A .....16 NoticetoPharmacists

March/April2008

INSIDE:Logged Prescriptions ≠ Refill Prescriptions . . . . . . . . . . . . . . . . . . .14Nurse Practitioner is Now a Protected Title . . . . . . . . . . . . . . . . . . .19National Pharmacy Technician Competencies . . . . . . . . . . . . . . . .27

. . . . . . . . . . page 7

Council MembersCouncil Members for Districts 1-17 are listed belowaccording to District number. PM indicates a publicmember appointed by the Lieutenant-Governor-in-Council. DFP indicates the Dean of the Leslie DanFaculty of Pharmacy, University of Toronto.DSP indicates the Director, School of Pharmacy,University of Waterloo.

1 Joseph Hanna2 ElaineAkers3 Sherif Guorgui4 Tracey Phillips5 Donald Organ6 Fayez Kosa7 Tracy Wiersema8 Saheed Rashid9 Bonnie Hauser10 Gerald Cook11 David Malian12 Peter Gdyczynski13 Donald Stringer14 Stephen Clement15 Gregory Purchase16 Doris Nessim17 Shelley McKinneyPM Joinal AbdinPM Thomas BaulkePM Andrea ChunPM Babek EbrahimzadehPM David HoffPM Margaret IrwinPM Lewis LedermanPM Aladdin MohagheghPM Gitu ParikhPM Krishanthy ShuDFP Wayne HindmarshDSP 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 PracticeWorking Group

• Working Group on Certificationof Pharmacy Technicians

• Working Group on Pharmacy Technicians

Mission Statement

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.

ONTAR IO COLLEGE OF PHARMAC ISTS

Keep informed and up-to-date on

Visit the website

and find helpful

fact sheets for

your interest

and information.

Pandemic planning

Pharmacy Connection

The objectives of Pharmacy Connectionare to communicate information on Col-lege activities and policies; encourage dia-logue and to discuss issues of interest withpharmacists; and to promote the pharma-cist’s role among our members, alliedhealth professions and the public.We publish six times a year, in January,March, May, July, September and Novem-ber. We welcome original manuscripts(that promote the objectives of the jour-nal) for consideration. The Ontario Col-lege of Pharmacists reserves the right tomodify contributions as appropriate.Please contact the Associate Editor forpublishing requirements.We also invite you to share your com-ments, suggestions, or criticisms by letterto the Editor. Letters considered forreprinting must include the author’sname, address and telephone number. Theopinions expressed in this publication donot necessarily represent the views or offi-cial position of the Ontario College ofPharmacists.

Public Education Program takes new steps forward . . . . . . . . . .7

Canada’s Newest Pharmacy Program . . . . . . . . . . . . . . . . . . .12

Logged Prescriptions ≠ Refill Prescriptions . . . . . . . . . . . . . . .14

Nurse Practitioner is Now a Protected Title . . . . . . . . . . . . . . .19

National Pharmacy Technician Competencies . . . . . . . . . . . . .27

Registrar’s Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Editor’s Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

SPT Q&A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Practice Q&A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Notice to Pharmacists . . . . . . . . . . . . . . . . . . . . . . . . .18 & 20

Health Canada Notices . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

Inspector’s Corner - Securing Your Pharmacy . . . . . . . . . . . . .24

Registration Q&A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Deciding on Discipline . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

ISMP - Near Miss Identification and Reporting . . . . . . . . . . . .36

Coroner’s Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

Focus on Error Prevention . . . . . . . . . . . . . . . . . . . . . . . . . .40

Bulletin Board . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41

CE Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

Ontario College of Pharmacists483 Huron StreetToronto, ON Canada M5R 2R4Telephone (416) 962-4861Facsimile (416) 847-8200www.ocpinfo.com

Peter Gdyczynski, R.Ph., B.Sc.Phm.President

Deanna Williams, R.Ph., B.Sc.Phm., CAERegistrar

Della Croteau, R.Ph., B.S.P., M.C.Ed.Editor, Deputy Registrar,Director of Professional [email protected]

Sue RawlinsonAssociate [email protected]

Agostino PorcelliniProduction & Design

Neil HamiltonDistribution

ISSN 1198-354X© 2008 Ontario College of PharmacistsCanada Post Agreement #40069798

Undelivered copies should be returnedto the Ontario College of Pharmacists.

Not to be reproduced in whole or in partwithout the permission of the Editor.

4 Pharmacy Connection March • April 2008

It seems like just yesterday thatwe were wishing each otherHappy Holidays, and making our

New Years resolutions. Yet in whatseems like no time at all, winter isalmost behind us as we prepare forthe upcoming “season of renewal”-Spring.Unlike other seasons, Spring is

truly a season where life forms thathave lain dormant over the cold,dark winter months literally “spring”back to life. I can’t help but drawcomparisons between the similarcycle of dormancy and new growthin Pharmacy.While there are clear exceptions,

in my view pharmacy practice gen-erally has coasted in a relatively“dormant “place for the past thirtyplus years that I have been a phar-macist. I can recall when “ClinicalPharmacy” was all the buzz in theearly 70s, followed by another new

phenomenon called “Pharmaceuti-cal care” twenty years later. Havewe, as a profession, truly sprungforward over the past thirty years? Iwonder…..Of course, there have always

been those pharmacists who, by allaccounts, would have been consid-ered by their peers to practice,“beyond the reaches” of traditionalpharmacy practice. When I gradu-ated it was less common to knowpharmacists who operated “dispen-sary-only” health centred pharma-cies or who made a living withoutdepending on the traditional “countand pour, lick and stick” role. Butthey did exist and they were my rolemodels. They taught me - way backthen- to fully use the knowledge,skills, ability and judgement that Ilearned while becoming a pharma-cist, to best serve and optimize mypatients’ care. That is really what it’sall about - it’s really what leads tosuccess and satisfaction for us aspharmacists and for our patients onwhose loyalty and business wedepend. And if you think about it-isn’t that what “pharmaceutical

care” was all about?Throughout the next two years,

as the College continues its devel-opment of “pharmacy technicians”as newly regulated professionals, weare working concurrently towardsenabling pharmacists who wish touse their professional knowledge,skills, abilities and judgement ininnovative ways, to be able to do soand do so legally. Experience showsthat once the value of a personand/or their services are recognized,there is no stopping their momen-tum. I believe this too can be thecase for pharmacists.

R E G I S T R A R ’ S M E S S A G E

Deanna Williams, R.Ph., B.Sc. Phm., CAERegistrar

Pharmacy Connection March • April 2008 55Pharmacy Connection March • April 2008

“Have a question about yourmedication? Talk to yourpharmacist – the medica-

tion expert you can rely on.” This isthe theme of our new public educa-tion program that you may have

already seen on TV and will be seeingin upcoming magazines.The Ontario College of Pharma-

cists has been running ads for thepublic throughout the last 6 years toencourage them to seek advice fromtheir pharmacist, and to appreciate

that the pharmacist is an expert inmedications. In addition, the adver-tisements sponsored by the provincialgovernment in regards to MedsCheck also created an awareness ofthe public that pharmacists can pro-vide them with complete medicationhistories and help to solve their drug-related problems.As medical therapies become

more complex, and the number andtypes of drugs increase, there is a

growing need for pharmacists to con-tribute their expertise on medicationsfor both patients and other healthcare professionals. Continuing edu-cation opportunities have never beenmore available. Pharmacists can nowsit in their own home at their com-

puter and have access to high qualitycontinuing education developed bysome of our top educators acrossCanada.Some workplaces have created a

culture of learning for their pharma-cists and their patients, while othersstick to the traditional roles. Each ofus needs to look within our practiceat the services we provide to the pub-lic, both individually and as a team.The public are coming! And theyexpect a medication expert! How canyou make that happen?

E D I T O R ’ S M E S S A G E

Della Croteau, R.Ph., B.S.P., M.C.Ed.Deputy Registrar/Director of ProfessionalDevelopment

...there is a growing need for pharmacists tocontribute their expertise onmedications for bothpatients and other health care professionals.

Pharmacy Connection March • April 20086

FEE PAYMENTS

Annual Pharmacy Fees dueMay 10, 2008Pharmacy fees of $810.31 ($771.72 + $38.59 GST) mustbe received and/or postmarked no later thanMay 10.

Paying by ChequeMake sure your cheque is signed andmade payable tothe Ontario College of Pharmacists or OCP in theamount of $810.31 ($771.72 + $38.59 GST) . Pleasewrite your Pharmacy Accreditation number and Invoicenumber on the front of your cheque.NSF cheques are treated as late and incur both a latepenalty fee and a $20 NSF service charge. All unsignedcheques will be returned for signature.

Paying by Credit CardWe accept payment by VISA, MasterCard or AmericanExpress. Enter your credit card number and the expirydate of your credit card in the box under PaymentInformation on your renewal form. Please be sure tosign the credit card section giving us authorization toprocess the credit card payment in the amount of$810.31.

Once processed, the certificates of accreditation andincome tax receipts are mailed to the Pharmacy.

LATE PAYMENTS

Late payments are subject to a late payment fee of $105($100 + $5 GST) (if paid within 30 days after the duedate) or $157.50 (if paid more than 30 days after thedue date). This includes cheques that are received earlybut postdated after May 10, 2008. Late payments arenot processed until the late payment fee has beenreceived.

RECORDS UPDATE

Updates are required forthe following:•Which pharmacists(with and withoutsigning authority), andtechnicians are practisingat the pharmacy

• Lock and leave practices• Methadone dispensing• Pharmacy website information• Indication of which of the College-approved DrugInformation Services the pharmacy subscribes to

As outlined in the Standards for DesignatedManagers,acknowledgement of all directors and designatedmanagers is a requirement of every pharmacy whenreporting a designatedmanager change. You canupdate this information on the renewal form ordownload the Acknowledgment/Change of DesignatedManager form by clicking on the “college forms” link atthe bottom of our home page at www.ocpinfo.com

(All fees listed above include GST)

For further information contact:Client Services at (416) 962-4861 Ext. 300or by email at [email protected]

Pharmacy AccreditationRenewals 2008

Your annual pharmacy accreditation renewal fee of $818.02is due no later than May 10, 2008. Renewal forms will be

mailed to each pharmacy by mid-March.

Pharmacy Connection March • April 2008 7

This Spring, our 2008 Public Education Program kicks off

with the airing of our television commercial and a new “call

to action” tagline asking Ontario’s public to “Talk to your

pharmacist…the medication

expert you can rely on”.

The commercial was aired

on major networks for seven

weeks beginning the week

of January 21st.

Public EducationProgram takes new

steps forward…


Public Education Programtakes new steps forward…

Recognizing that adults aged 50 and over are the most likely group to beonmultiple medications, last Fall we conducted focus groups to test therelevance of our commercial messages with this audience. The researchresults suggested that the message was relevant, the animation was aneffective delivery method, and that once they are made aware, this udiencehighly values the advice and information pharmacists have to offer them.With this in mind, we have decided to focus our media strategy on selectedtelevision programming that specifically targets and reaches this audience.To further support the delivery of our message to Ontario’s public, we have

also purchased ad space in four magazines that have the highest readershipamong those “50-plus”. The ads (seen at right) align with the look and feel ofthe television commercial, featuring our “Heart” character consulting with hispharmacist, and amessage that positions the pharmacist as “the medicationexpert you can rely on”. These ads are planned for April issues - perfecttiming to extend the reach and frequency of our message, since ourcommercial ends its runmid-March.

Watch for these new ads to appear in theApril editions of these magazines:• Readers Digest• Canadian Living• Canadian Gardening• Homemakers• CARP (Canadian Association ofRetired Persons)


The awareness generated by the television commercial and printadvertising will be further reinforced in-pharmacy, with a new countersticker (see below) that will be distributed to all pharmacies inFebruary.Our Public Education Program takes a brief interlude in the summer

months, then will resume late September with another 7-week airingof the television commercial, followed again by a revised print ad inthe same four magazines – November issues, and another newcounter sticker for all pharmacies.


Pharmacy Inspector

Professional Opportunity:

TheOntario College of Pharmacists is currently seeking a highlymotivated pharmacist interested in join-ing the College in the capacity of Pharmacy Inspector. The successful candidatewill possess strongcommunication skills and the desire to assist pharmacists in understanding and complyingwith the leg-islative requirements and College policies to ensure operational standards are adhered to in both newlyaccredited and existing pharmacies.

As a representative of the College, the individual will be responsible for themonitoring of and complianceto professional Standards of Practice, aswell as to the operational standards for pharmacies. The individ-ual will play an active role in assisting pharmacistswith practice issues by educating pharmacists eitherindividually or in groups. The successful candidatewill also provide feedback frompharmacists on recom-mendations for regulatory changes. The individualmay be requested to participate inmeetings such asAccreditation and Professional Practice.

This is a challenging position for the right individual willing toworkwith front line pharmacists in a varietyof practice settings. A good grasp of the relevant legislation, issues and challenges facing pharmacistsand pharmacy practice is essential.

The candidate possesses strong organizational, written and verbal communication skills and is able totravel extensively throughout the province.

If you are interested in joining the College staff in this position, please forward your resumebyApril 4, 2008 in confidence stating salary expectations to:

Connie Campbell,Director of Finance and Administration

Ontario College of Pharmacists483 Huron Street, Toronto, ONM5R 2R4fax: (416) 847-8279 • email: [email protected]

Wewish to thank all applicants for their interest in this position. Only those candidates chosen

for an interviewwill be contacted.

Please apply for this position by:April 4, 2008


QCan Structured Practical Training (SPT) becompleted in a practice site other than acommunity or hospital pharmacy?

According to the SPT Practice Site Criteria, students/internsmust complete training in a practice site that is “accred-ited” (i.e., community pharmacy) and/or a hospital orother site in Ontario in which direct patient care is pro-vided.” SPT helps students/interns make the transitionto practice through experiential training and allows forassessment of their entry-to-practice competenciesaccording to NAPRA (National Association of PharmacyRegulatory Authorities - www.napra.org) in 1997.Alternative practice sites for SPT may increasingly

come under consideration as the pharmacist’s roleexpands into collaboration within family health units, oninterdisciplinary teams in any practice setting and at long-term care facilities. An alternative practice site may beeligible for SPT, provided the student/intern experiencesdirect patient care situations involving pharmaceuticalcare, drug distribution, patient education, drug informa-tion, and management of pharmacy practice. SPT assess-ments and activities designed to structure the trainingare based on these entry-to-practice competencies andmust be completed at the practice site to demonstratethe student/intern’s readiness for practice and eligibilityto register as a pharmacist.If you work in an unconventional practice site and

would like to participate in SPT, please review the SPTPractice Site Criteria and the SPT assessments and activ-

ities, available on the OCP website by clicking on Licens-ing > Training and Assessments > SPT, to determine ifyour site meets the goals and objectives of SPT. Contacta Registration Advisor at the College for consideration ofyour site.

QAre the SPT assessmentsavailable online?

The SPT assessments for Studentship and Internship areavailable on the OCP website by clicking on Licensing >Training and Assessments > SPT, then the required doc-ument. Currently, the online assessments must be printedfor manual completion and record-keeping.In keeping with the College’s strategic plan to increase

web-based communication, we are looking into how pre-ceptors and students/interns would be able to electroni-cally access, complete, and submit the assessments. Oneof the first steps of this project will be a review of the SPTassessment tool. The competencies upon which the assess-ments are based were updated by NAPRA in 2007 andwill be considered by Council for implementation in SPT.Focus groups of recently registered pharmacists and

experienced preceptors will be held in the spring to dis-cuss the SPT assessment forms and processes and todetermine how to streamline them, while preserving theircomprehensiveness. Comments and suggestions regard-ing the SPT assessments are welcome and may be for-warded to the Registrations Program through the SPTassistant, Vicky Gardner at [email protected].

Structured Practical Training

QA&Diana Spizzirri, R.Ph., B.Sc.Phm., M.Ed.Deanna S. Yee, R.Ph., B.Sc.Phm., M.Sc.,Registration Advisors


Canada’s NewestPharmacy Program

THE UNIVERSITY OFWATERLOOWELCOMES ITS

FIRST 92 STUDENTS!

Canada’s NewestPharmacy ProgramCanada’s NewestPharmacy Program


The pharmacy students, who began studying on Jan. 7, come from across

the country.Womenmake up about 60 per cent of enrolment and 40 per

cent of all students already hold a degree. The students are already

deeply immersed in courses including physiology, pharmaceutics, professional

practice, communication skills, metabolism, and computing for pharmacists.

UW offers one of only two co-op pharmacy programs in North America. The

students will embark on their first co-op terms in September 2008, following

two terms of academic study. International co-op experiences are encouraged.

More than 800 potential employers have already expressed interest in hiring

pharmacy students.

On Jan. 9, the class was welcomed to the profession with aWhite Coat

Ceremony. The ceremony is a tradition in many health profession programs,

particularly pharmacy andmedicine. The white lab coat is symbolic of the

tremendous responsibility that pharmacists hold as health care providers. As

the students embark on their professional journey, this ceremonymarks their

commitment to ethics and integrity. Speakers included representatives from

UW, the Ontario Pharmacists' Association, the Ontario College of Pharmacists,

and the Region ofWaterloo Pharmacists' Association. The students jointly

took a pledge of professionalism. Their white coats were presented by

practicing pharmacists who had served as team leaders in the applicant

interview process.

The application process for the next class is well underway. The application

deadline is January 31, 2008, and detailed application information is available

at http://www.pharmacy.uwaterloo.ca/prospective. UWwill accept up to 120

students.


Several dispensing errors related to the process of logging andsubsequent dispensing of logged prescriptions have beenbrought to the attention of the Complaints Committee

through formal complaints. For the purpose of this article, logginga prescription refers to putting it on hold upon request by a patient.Other terms referring to the same process may be used in individ-ual pharmacies.There appears to be a misconception that if a logged pre-

scription hardcopy is checked for accuracy by a pharmacist at thetime the prescription is logged, the Dispensing Pharmacist has tocheck the hardcopy only and does not have to refer to the origi-nal prescription when dispensing the medication to the patient.The process of checking a hardcopy only routinely occurs duringthe dispensing of a prescription refill. It is important for pharma-cists to recognize that the process for dispensing a logged pre-scription is not identical to the process for dispensing a prescrip-tion refill. The illustration on page 15 describes the two processesand highlight the differences.While a Dispensing Pharmacist is not expected to check a pre-

scription hardcopy against the original prescription when dispens-ing a refill (unless a therapeutic intervention or discrepancy is iden-tified), a Dispensing Pharmacist is expected to thoroughly check ahardcopy against the original logged prescription to ensure thatthe medication is dispensed as prescribed.The difference in these dispensing processes arises from the

simple fact that for a prescription refill, the original prescription andhardcopy were thoroughly and completely reviewed when the drugwas initially dispensed. Conversely, the initial check that occurs

Shelina Manji B.Sc., B.ScPhm., R.Ph.Investigator

Pharmacists engage in a number of processes during the course of practicing

their profession. The standards of practice for both designated managers and

pharmacists require the assessment of these processes to ensure that they are

designed to minimize adverse events.

Logged Prescriptions


when a prescription is logged, while considered best prac-tice for ensuring correct information is recorded on thepatient’s profile, is certainly not a complete check anddoes not negate the necessity to check the hardcopyagainst the original prescription when the medication isbeing dispensed. Thus, the process for dispensing a loggedprescription is identical to the process for dispensing anew prescription.The following complaint reviewed by the Complaints

Committee will illustrate the limitations of checking onlya hardcopy when dispensing a logged prescription.

ComplaintThe Complainant’s mother (“the Patient”) was prescribed4 tablets of Warfarin® 1mg to be taken once daily. The

Patient noted that she received Warfarin® 4mg withdirections to take 4 tablets once daily. The Patient con-tacted the pharmacist and was informed that the physi-cian must have prescribed the dose dispensed. Thisresulted in the Patient contacting the physician to verifythe dose and the physician in turn, informing the phar-macist that a dispensing error had occurred.

Pharmacists’ ResponseThe Designated Manager of the pharmacy explained thatthe prescription had been transferred to them and hadbeen incorrectly logged. She described the procedure forlogging prescriptions as one where the prescription was

≠ Refill Prescriptions

continued on page 17


QWhy is a prescription that is put onhold fora patient not treated the sameasaprescription refill?

Simply stated, the prescription has not yet been filled.Therefore refilling is not an applicable process. Puttinga prescription on hold is a service provided by pharma-cists. They are storing an unfilled prescription for futureuse by the patient. Processing it in the pharmacy com-puter system and giving it a number merely provides foreasy retrieval.

QIf it is not a refill, what arethe differences?

Although filling a prescription does not appear compli-cated, the process of filling a new prescription goesthrough several critical checks (This is not meant to be acomplete process, rather an overview of the general processwhen filling and checking a new prescription).• Person receiving the prescription gathers all the appro-priate personal health information and checks that theprescription is written for the correct patient.

• Person processing the prescription (may be same asabove) enters the patient information into the phar-macy computer system, chooses the drug, checks foralerts and reviews the patient’s prior history.

• Person filling the drug checks the prescription againstthe printout and labels and verifies the selected drug iscorrect.

• Pharmacist checks the finished product and verifies itis the right patient, drug, condition, dose and route of

administration by checking the original prescription,and follows up on any alerts or necessary interventions.

• Pharmacist (may be the same as previous point) pro-vides the patient with the prescription and counsels thepatient regarding the drug, which acts as a final check.If the pharmacist is not the one who signed off on theprescription, the original prescription is normallyattached to the waiting finished prescription for a phar-macist to check while counselling the patient.A new prescription should go through a number of

checks and double checks, according to the systems inplace at the pharmacy, prior to the patient receiving theprescription. Such checks are important to ensure thesafe and appropriate dispensing and use of the drug. Thisforms the basis of a safe practice, also identified by theInstitute for Safe Medication Practices (ISMP-Canada).A prescription being refilled has already been subject

to all the above steps. A logged or on hold prescriptionhas only gone through the first two steps. Logging a pre-scription splits the dispensing of a new prescription andmisses the last three steps and a number of importantchecks and double checks.A logged prescription is a new, unfilled order. The

question a pharmacist should consider is whether ornot they normally check the original against the com-puter generated hard copy before “signing off” a newprescription or do they only check the computer gen-erated hard copy? The answer to this question providesthe basis for the process of dispensing a logged pre-scription.

PRACTICE

QA& Greg Ujiye, R.Ph., B.Sc.Phm.Professional Practice Advisor


QAre there any regulatory requirements forlogged prescriptions?

There are no regulatory requirements for logged pre-scription. Since a logged prescription has not been filledand a pharmacy is holding it for the patient, the loggedprescription still belongs to the patient. The patient hasasked the pharmacist to hold on to it for safe-keeping.However there are specific requirements for new and

refilled prescriptions which can be found in the Drug andPharmacies Regulation Act and subsequent regulations.Section 156 of the DPRA identifies information the dis-pensing pharmacist is required to have on the prescrip-

tion when it is dispensed. This section refers to the phar-macist dispensing the prescription, the date on which thedrug was dispensed and the price charged, not the datethe prescription was processed or logged.

QI have a number of old prescriptions still onhold. Can I destroy them?

As you are providing a service and holding these pre-scriptions for safe-keeping for the patient, the prescrip-tions still belong to the patient. You will need to contactthe patient and get consent to destroy any prescriptionson hold.

processed, the hardcopy generated was affixed to the pre-scription which was then reviewed by a pharmacist beforebeing filed with the rest of the prescriptions. The Dis-pensing Pharmacist advised the Committee that whendispensing a logged prescription, the hardcopy that is gen-erated is not checked against the original prescription asit is expected that a pharmacist had already performedthis check when the prescription was logged.

Decision and ReasonsThe Committee expressed its concerns that logged pre-scriptions were filed together with prescriptions thathad been dispensed and that these logged prescriptionswere not being thoroughly checked before being dis-pensed. The Committee determined that logged pre-scriptions must be checked in the same manner as newprescriptions as in both instances, the medications arebeing dispensed for the first time. Consequently, theCommittee issued a strong reminder to the DesignatedManager to ensure that systems were in place at thepharmacy that clearly defined who was responsible forchecking a logged prescription and when this checkshould occur.The Committee noted that although the dispensing

error resulted from an incorrectly logged prescription, theDispensing Pharmacist was responsible for the error forthe following reasons:

• She failed to check the prescription completely andthoroughly before dispensing the medication.

• She failed to use her therapeutic knowledge to assessthe consequences of 16mg of Warfarin® on the Patient.

• She failed to review the Patient’s medication profilewhich would have indicated that the Patient had neverpreviously been prescribed such a high dose.

• She failed to confirm the dose with the physician.• She failed to follow up appropriately when the Patientexpressed her concerns about the dose.

Due to the above concerns, the Committee directedthe Dispensing Pharmacist to attend at the College toreceive an Oral Caution and also directed her to suc-cessfully complete remediation related to both anticoag-ulation therapy and medication errors.

ConclusionWhile this article focuses only on the process for loggingand the subsequent dispensing of logged prescriptions, itis prudent for pharmacists and designated managers tocritically analyze all the processes in place at a pharmacyto identify any steps or gaps in the processes that createan inherent risk for an error to occur. Once this analysisis completed, appropriate modifications to the processesshould be undertaken to ensure that systems are in placeto prevent the occurrence of adverse events.

continued from page 15

Logged Prescriptions ≠ Refill Prescriptions


NOTICE TO PHARMACISTS

FORGERY ALERTOut of Province Prescriptions

Possible diversion or fraud is always a real possibility especially with narcotics. Pharmacists are expected touse due diligence and verify any unknown narcotic prescription whether it is written locally or out of theprovince.

Recently a very sophisticated scam to obtain narcotics was reported to the College. This involved a request fora narcotic from an out of the province physician for a patient travelling to Ontario for an emergency. The circum-stances and the demeanour of the person impersonating the physician were compelling and believable. The actualphysician when contacted reported receiving at least a half dozen calls from Ontario pharmacies regarding thisfraud.

The person impersonating the physician called the pharmacy late in the afternoon on the weekend and providedall the pertinent physician information. The physician also provided the circumstances for the emergency requestfor Oxycontin® and Percocet® all of which were compelling as they involved, in this case, a child’s unexpected deathand the mother, who was coming to Ontario, under treatment for cancer. This person was very sophisticated andbelievable and did not arouse the suspicion of the pharmacist at any time.

The pharmacist checked various directory services and called back the physician’s office as listed in the provin-cial directory. When the pharmacist did not get an answer, he/she called the number given by the physician andreceived a recording from a supposed after hours clinic. A second attempt connected the pharmacist with a per-son who indicated the doctor was with a patient and would call back as soon as possible. When the doctor calledback, the pharmacist asked the doctor for their office number which the doctor did without hesitation and explainedthat this was their weekend to work a shift at the clinic.

When the doctor proceeded to provide a verbal for the narcotics, the pharmacist indicated that a written pre-scription was required and provided the pharmacy fax number. Shortly after the mother called asking about theprescription and was told the pharmacy was awaiting a fax and she did not raise any concerns or attempt to pres-sure the pharmacist. The pharmacist attempted to call the clinic again and in the middle of the conversation thephone went dead. A fewminutes later the doctor called back and apologized explaining the weather had been caus-ing problems with the phone systems, which given the time of year, was very plausible. During this time the patientarrived and her condition appeared consistent with the doctor’s information and did nothing to arouse the suspi-cion of the pharmacist. The fax machine was activated and stopped twice during this time.

Since it was close to closing, the pharmacist again called the doctor who told him they were having problemswith the fax machine. A fax was never received and upon contacting the physician on the Monday, the physiciandenied any knowledge and indicated that they had received several calls from Ontario regarding this fraud.

Summary

Pharmacists are put in this situation on a regular basis. Drug seeking individuals are very manipulative andcan provide compelling or believable scenarios. Although the pharmacist in this situation believed he hadtaken reasonable steps to verify the physician and although the circumstances surrounding the patient wereplausible, the pharmacist was manipulated. Options were still available for the patient to obtain a written pre-scription, for example, a local walk in or emergency department at the hospital. Without the written or faxedprescription, a narcotic drug cannot be dispensed particularly when the patient or doctor is not known.


The College of Nurses ofOntario (CNO) has regu-lated Registered Nurses in

the Extended Class (RN(EC)s)since 1998. These RN(EC)s arenurses who have the independentlegal authority to communicatediagnoses, order certain laboratorytests, x-rays and ultrasounds, andprescribe certain drugs. On August29, 2007 new regulations werepassed to legally protect the title“nurse practitioner” and the abbre-viation “NP” and to limit their useto RN(EC)s. This means that phar-macists may start to receive pre-scriptions signed by nurses identify-ing themselves as NPs, in additionto those signed by nurses who con-tinue to use the RN(EC) terminol-ogy. CNO has confirmed that useof either title is permitted. NPsmay also choose to further indi-cate their specialty designation;that is, whether they are an NPin the Adult, Paediatrics orPrimary Health Care spe-cialties. All NPs mustdocument theirCNO registrationnumber on eachprescription.

CNO has spent the past severalmonths – before and after the regu-lations were passed – educating itsmembers about title protection.Nurses who are not in the extendedclass, but historically used the NPtitle, have been required to stop theuse of the NP title until such timeas they are registered in theextended class. It is up to nurses, asself regulating professionals, to usetheir legal titles appropriately. Asalways, if pharmacists need to verifywhether a nurse is an NP, they cando so by contacting CNO’s customerservice line at: 416 928-0900 or 1800 387-5526 (toll free in Ontario)A prescription received from an

NP for a drug that he/she is legallyauthorized to prescribe is not to

be confused with prescriptions youmay receive written through the useof authorizing mechanisms, such asdirectives. A directive is most oftenauthorized by a physician. Nursesmay use directives to implementprescriptions under conditions thathave been defined by physicians.The directive reflects the physi-cian’s prescription and must clearlystate the physician’s name, addressand contact information. Nurseswho use directives must identifythemselves as either an NP or RN.A template for prescriptions writtenpursuant to a directive can befound at: http://mdguide.regulated-healthprofessions.on.ca/pdf/Recom-mendedFormat.doc

Nurse Practitioner isNow a Protected Title


NOTICE TO PHARMACISTS

AMENDMENTS TO THE DRUG AND PHARMACIES REGULATION ACT

DELIVERY OF MEDICATIONS

Mailing of Drugs

152. Drugs referred to in Schedules D, E, F, G and N shall be sent through the mail only by registeredmail. R.S.O. 1990, c. H.4, s. 152.

Note: Effective June 4, 2008 or on an earlier day to be named by proclamation of the Lieutenant Gov-ernor, section 152 is repealed by the Statutes of Ontario, 2007, chapter 10, Schedule L, section 16and the following substituted:

Mailing or delivering certain drugs152. (1) Subject to subsection (2), a drug listed in Schedule I shall, if sent through the mail, only besent by registered mail or, if delivered by another method, shall be delivered in a method that is bothtraceable and auditable, with a receipt for the drug signed by the patient or the patient’s agent.2007, c. 10, Sched. L, s. 16.

Exception, federal law(2) Where a law of Canada permits a method of delivery of a drug other than provided for in subsec-tion (1), the law of Canada prevails. 2007, c. 10, Sched. L, s. 16.

Impending changes to the Drug and Pharmacies Regulation Act (DPRA) will directly impact pharmaciesthat deliver or ship medications to patients. These amendments were made to update and clarify the leg-islation, the intent being to ensure for the patient, the safe delivery of medication as well as to protecttheir personal health information.

Effective June 4, 2008 (or earlier), the DPRA s. 152 will be repealed and replaced by the amended DPRA s.152 (1), (2). Any drug requiring a prescription, i.e. Schedule I, that is shipped or delivered will require thepatient or their agent to sign that they have received the drug. In addition the method of shipping will haveto be auditable and traceable.

Pharmacists using courier services or other methods of delivery should review their processes and wherenecessary, implement policies or procedures to comply with the new requirements. Pharmacists are respon-sible for ensuring patients receive the correct medication. In addition as a health care custodian they areresponsible for the protection of the personal health information of patients. This means that, pharmacistsshould take reasonable steps when preparing prescriptions for delivery to prevent access to confidential infor-mation.

A delivery person is acting on behalf of the pharmacist and is considered an agent of the pharmacist. Assuch delivery or courier personnel cannot act independently or without the permission of the pharmacistregarding deliveries of prescription drugs. Pharmacists are ultimately responsible for the prescription until thepatient or agent has taken custody of the delivery. In order for the delivery to be traceable and auditable, deliv-ery personnel are expected to notify and receive permission from pharmacists for any unauthorized stops ortrips that interfere with the direct delivery of medications to the patient.

Where patients indicate it is acceptable for an agent to receive their prescription order, that informationshould be provided to the pharmacy prior to delivery in order to avoid any confusion or unnecessary delaysin the patient receiving their medication. Wherever possible, the agent should be identified prior to a deliv-


ery and all information documented and provided to the driver or courier service. When a patient is not homeand no prior arrangements have beenmade, the prescription can be left with an appropriate agent as determinedby the pharmacist. In all cases the receipt of the prescription must be documented with a signature.

There is some belief that the patient can name the delivery person as their agent. This is not acceptable asthe delivery or courier is already an agent of the pharmacist and to be named an agent of the patient would bea conflict of interest.

When a postal service is used, the pharmacist may at his/her discretion permit the parcel to be left at thelocal postal station if they are satisfied that the storage conditions and security of the prescription can be main-tained and signature obtained.

For pharmacies with delivery personnel on staff, systems and procedures should be put in place to ensurethat delivery personnel are aware of the amendments to the DPRA as well as to inform patients of the changes.

It should be emphasized to patients that the changes in the Act are implemented to ensure the safe deliv-ery of medications to protect both the patient and the public as well as to protect a patient’s personal healthinformation.


DATE TYPE

4 Dec 2007

12 Dec 2007

18 Dec 2007

21 Dec 2007

28 Dec 2007

28 Dec 2007

2 Jan 2008

2 Jan 2008

2 Jan 2008

2 Jan 2008

23 Jan 2008

6 Feb 2008

HEALTH CANADAAdvisories&Notices

Health Canada reminds Canadians of precautions during cold and flu seasonCold and flu season in Canada runs from November until April. Health Canada would like to remind Canadians of theimportant safety precautions they should keep in mind to protect themselves and their families.

Three Lots of Measles, Mumps and Rubella Vaccine Suspended from UseHealth Canada is advising provincial and territorial health authorities not to use three lots of measles, mumps andrubella vaccine while the Department investigates five suspected cases of anaphylaxis in Alberta patients receivingthe product.

Important Safety Information on ALERTEC (modafinil)New warnings regarding ALERTEC®* (modafinil) and severe cutaneous adverse reactions, serious hypersensitivityreactions and psychiatric symptoms

Important Safety Information on NULTIVA (Remifentanil hydrochloride)Recall of NULTIVA® (remifentanil hydrochloride) 1 mg vials due to potential for overdose

Use of Unlicensed Pap-Ion Magnetic Inductor May Pose Health Risk Health Canada is advising Canadians not to use oraccept treatment with the Pap-Ion Magnetic Inductor (PAP-IMI), an unlicensed medical device that may pose healthrisks. Use of this device may be linked to patient injury and death in the United States and may delay or interfere witheffective treatment of an existing health condition.

Unauthorized health products manufactured by Wild Vineyard may pose health risksHealth Canada is advising Canadians not to use unauthorized products manufactured by Wild Vineyard because of thepotential health risk to consumers. Wild Vineyard is not authorized to manufacture, package, label or import naturalhealth products in Canada. As such, Health Canada is concerned about the quality of these products and thesubsequent health risk that they may pose to Canadians.

Important Safety Information on Baby's Bliss Gripe Water (apple flavour), code 26952VBaby's Bliss Gripe Water (apple flavour), code 26952V, a natural health product given to infants to ease stomachdiscomfort and gas, was found to contain the parasite cryptosporidium. Cryptosporidium may cause severe, chronicor even fatal effects, especially in infants.

Important Safety Information on Zhong Ti Xiao Er Jian Pi San (batch number JPS0704)Zhong Ti Xiao Er Jian Pi San is a natural health product. Batch number JPS0704 has been recalled due to microbialcontamination.

Important Safety Information GalactogilLot numbers and expiry dates: 1040 (11/2007); 1438 to 1463 (04/2012 to07/2012); and 1466 to 1472 (08/2012)Galactogil is promoted as a natural product to stimulate lactation in nursing mothers. Certain lots should not beconsumed due to microbial (bacterial) contamination.

Important Safety Information Santi Bovine Penis Erecting CapsuleSanti Bovine Penis Erecting Capsule is promoted to treat erectile dysfunction. It has been found to contain sildenafil, aprescription drug that should only be taken under the guidance of a health professional.

Important Safety Information on YeniujynHealth Canada is warning Canadians not to use the unauthorized product Yeniujyn because the product containsheavy metal contaminants and may pose a serious health risk. Yeniujyn is advertised as a natural health product, foradults and children, to be used “to cure involuntary passage of urine diseases.” The product was found to containhigh levels of lead and arsenic.

Health Canada Update: Avian Influenza (Bird Flu)For most Canadians, the risk of getting avian influenza (bird flu) is extremely low. However, it is important to know howto minimize your risks, especially if you are traveling to an area affected by avian flu.


DATE TYPE

7 Feb 2008

7 Feb 2008

7 Feb 2008

7 Feb 2008

7 Feb 2008

7 Feb 2008

7 Feb 2008

7 Feb 2008

7 Feb 2008

Foreign Product Alert on Jingzhi Kesou Tanchuan; Guanxin Suhe capsules; Qing Re An Cang Wan; and Guan Xin SuHeHealth professionals and the public in the UK were alerted to these natural health products as they were found tocontain Aristolochia plant species, which contain aristolochic acid, a toxin associated with serious and potentiallyfatal health effects.

Foreign Product Alert on Xiao Qin Long CapsulesXiao Qin Long Capsules is a natural health product that has been found to contain aristolochic acid, a toxin associatedwith serious and potentially fatal health effects.

Foreign Product Alert on Xiao Qin Long Wan; Chuan Xiong Cha Tiao Wan Tablets; Bai Tou Weng WanXiao Qin Long Wan, Chuan Xiong Cha Tiao Wan Tablets and Bai Tou Weng Wan are natural health products that havebeen found to contain aristolochic acid, a toxin associated with serious and potentially fatal health effects.

Foreign Product Alert on Wannianqing Pai Danggui Niantong Tang (batch number 050401)Wannianqing Pai Danggui Niantong Tang is a natural health product that has been found to contain aristolochic acid, atoxin associated with serious and potentially fatal health effects.

Foreign Product Alert on VPX 'No Shotgun' and BSN 'Cell Mass' Body Building PowdersVPX 'No Shotgun' and BSN 'Cell Mass' Body Building Powders are promoted as body enhancing supplements. Theyhave been found to contain coumarin, a prescription drug which should be taken only if prescribed and closelymonitored by a health professional.

Foreign Product Alert on Ding Lu Brand Guipi Wan (batch number 060401); Ding Lu Brand Bushen Yijing Wan (batchnumber 060401); Ding Lu Brand Shiquan Dabu Wan (batch number 060401); Ding Lu Brand Xiangsha Liujun Wan(batch number 060401); Ding Lu Brand Xiaoyao Wan (batch number 060401); Medco Brand Vitality Essence Extract OfDeer Fetus (batch number 61007); Plasmin (batch number 20060102)The Health Sciences Authority of Singapore advised the public not to use certain batches of several natural healthproducts because they were found to contain potentially toxic levels of mercury or arsenic.

Foreign Product Alert on Yogaraja Gulgulu Pills (batch number GK039) and Pilsol CapsuleThe Health Sciences Authority of Singapore advised the public not to these products because they were found tocontain potentially toxic levels of arsenic and/or lead and/or mercury.

Foreign Product Alert on Conforer Global Yang Tonic-2 (batch number 060117)The Health Sciences Authority of Singapore advised the public not to use this product because it was found to containpotentially toxic levels of mercury.

Foreign Product Alert on Liang Gel San Concentrated Powder (batch number G3238913) and Qing Xin Lian Zi YinConcentrated Powder (batch number G3239274) The Health Sciences Authority of Singapore advised the public not touse these products because they were found to contain potentially toxic levels of mercury.

For complete information&electronicmailing of theHealth CanadaAdvisories/Warnings/Notices subscribe onlineat: http://www.hc-sc.gc.ca/dhp-mps/medeff/index_e.html

MedEffect e-Notice is the newnamewhich replacesHealth Canada'sHealth_Prod_Infomailing list. The content of thee-noticesyou receivewill remain the sameand are nowpart ofMedEffect, a newHealth CanadaWeb site dedicated to

adverse reaction information. MedEffect can be visited atwww.hc-sc.gc.ca/dhp-mps/medeff/index_e.html

Health CanadaNotices are also linkedunder “Notices” on theOCPwebsite:www.ocpinfo.com


INSPECTORS’ CORNERINSPECTORS’ CORNER

Securing YourPharmacy

By Nadia Sutcliffe, RPh, BScPhm - Inspector

This is a situation that many pharmacists have been in atone point or another. Sometimes, it is a false alarm andyou just have to deal with the annoyance of having been

awakened in the middle of the night for no reason. In theworst case scenario, you will have to spend hours at the phar-macy with the police, assessing the damage and losses incurred,not to mention all the clean up required, replacement of anybroken windows or fixtures, completing paperwork and dealingwith insurance companies.Picture another scenario. It is 10 minutes to closing. A

person walks up to the pharmacy counter. You look up andask if you can help him. He takes a gun out of his pocket anddemands that you give him narcotics. You nervously comply –trying not to make eye contact with him. He yells at you tohurry up as he waves his gun around carelessly. You hand overthe narcotics in a bag and he turns and runs out of the phar-macy. You sit down, stunned and shaken. You pick up thephone to call the police and start to worry that he might comeback again….There are some things that pharmacists can do to better

protect their premises from break-ins as well as robberies.Some are easy to implement and some take planning and con-struction. All are well worth it in the end in order to protect

It’s 12:30 am and the phone is ringing. It’s the alarm company informing

you that your pharmacy has been broken into. As you heave yourself out

of bed to quickly get dressed, you think to yourself – is there anything I

could have done to prevent this from happening?


your pharmacy, your staff and yourinventory.A key crime-fighting technique

for businesses and residences isCPTED – Crime PreventionThrough Environmental Design. Itis a pro-active technique whichstresses that “the proper design andeffective use of the built environmentcan lead to a reduction in the fear andincidence of crime”. It works by eliminat-ing criminal opportunities in and around yourproperty or business.CPTED’s most basic concept is to make your phar-

macy a less attractive target. One way to do this is tomake sure your premises (including the outside of thebuilding) are well lit and maintained. If possible, whenchoosing a location for your pharmacy, try to pick a sitewhich is not isolated and has high pedestrian traffic. Theend unit furthest away from all other retailers may notbe a good choice. Keep your windows clear of obstruc-tions – can people see clearly into your pharmacy? Wouldsomeone from outside the store be able to see that you arebeing held-up – can police see inside as they drive by?Do not clutter the area with posters and large productdisplays which can obstruct the view of a passer-by.Another question to ask yourself is, do you have a clearview of the window or door from the dispensary – canyou see who is coming or going? This would be useful ifyou needed to get another look at the perpetrator beforethey went out the door.Store security systems are also a good idea. Motion

detectors, safe and door alarms are highly recommended.Video surveillance is also a great deterrent. Be vigilant inthe placement of the cameras to ensure that they wouldget a clear picture of the perpetrator. It is also advisableto have a system that uses a 24 hour taping and that thehard-drive be kept offsite or at least in an inconspicuousplace. Thieves have been known to try to take the record-ing to conceal their identities. Highly visible signage stat-ing that the pharmacy is being monitored by video sur-veillance is also recommended. Make sure your locks arein good working order and that your doors are secure.

Any door leading to a receiving areashould be solid-core, dead-bolted andconnected to the alarm system. Win-dows can be reinforced with bars orsecurity film to delay entry to thepharmacy. Ensure that all narcoticand controlled drugs are stored in asecure fashion. Determine the bestmethod to secure your inventory of nar-

cotic and controlled drugs. The policeare a valuable resource for obtaining such

advice. Each police service throughout Ontariohas officers trained and willing to meet with pharmaciststo discus crime prevention and the application of CPTEDin your pharmacy. Check your local police service’s web-site for more information.There are a number of other things that a pharmacy

owner can do to minimize the potential for break-ins orrobberies.• Keep a minimal amount of narcotics/controlled drugsin the pharmacy

• Lock up your personal belongings• Do more frequent bank deposits to minimize theamount of cash being kept in the pharmacy

• Have signage stating that video camera surveillance isin use

• Situational awareness – always be aware of your sur-roundings and anyone that may be present

• Make sure your staff is visible and that they acknowl-edge customers in the pharmacy

It is important that all staff are trained in what to doduring a robbery. Fighting with a perpetrator shouldnever be option. Satisfying their requests will likely pre-vent injuries.Pre-planning for the worst case scenario can help to

greatly reduce the chances of it happening. Break-insand robberies are frightening experiences that everyonewould prefer to avoid if at all possible. Considering yourstaff ’s personal safety, your inventory, and the cost ofrepairs and insurance premiums, it would be wise to takesome steps to prevent these events from occurring – actrather than react.

INSPECTORS’ CORNERINSPECTORS’ CORNER


QI’m considering asking for an exemption fromthe International PharmacyGraduate Program(IPG Program).What should I consider indecidingwhether to do the programor seekanexemption from the registration panel?

In trying to decide whether to do the program, many peo-ple may look only at the cost of tuition and lost wageswhen they attend the program for 16 weeks. They do notconsider what it costs them not to do the program, andto thereby delay the licensing process -- because thefastest way to get licensed as a pharmacist is by doing theIPG program.The majority of international candidates who attempt

the PEBC Qualifying Exam without completing the IPGprogram are not successful on the first attempt. Becausethe exam is offered twice a year, they must wait sixmonths to rewrite the exam, and cannot do any struc-tured practical training in that time period because theydo not qualify to register as students. If they fail the qual-ifying exam on the second attempt, they will have to waitanother six months, and will have delayed starting theirstudentship by one year or longer. There are only fourattempts permitted with the PEBC Qualifying Exam; acandidate who fails the exam four times can never belicensed as a pharmacist in Canada.Even if a candidate passes the PEBC Qualifying Exam

on the first attempt, panels will consider the candidate’spractice experience and may require him/her to do up to32 weeks of structured practical training at the studentlevel. Graduates of the IPG program are required to com-plete only 16 weeks of structured studentship.Approximately 93% of those who successfully com-

plete the IPG program are successful on the qualifying

exam and can often complete all the licensing require-ments within a year.So, if you are considering the cost of the program,

you should also consider the opportunity cost if you delayyour licensure as a pharmacist.

QThe IPG programat the University of Toronto isexpensive.Whydoes it cost somuch?

The IPG program is composed of two eight-week modulesCanadian Pharmacy Skills I,(CPS l) and Canadian Phar-macy Skills ll, (CPS II) each costing $6500. The intentof the program is to help candidates meet the entry-to-practice requirements by teaching them communications,patient counselling, pharmacy practice, jurisprudence,therapeutics, and enculturation to the Canadian healthcare system. Students in the program get extensive prac-tice in interviewing and counselling patients. The pro-gram not only prepares them for the qualifying exam butalso to become effective pharmacists.The university is a not-for-profit organization, and the

cost of the program, though it may seem high, reflectsthe expense of delivering it. The costs of bridging pro-grams of similar length in other professions such as nurs-ing, medicine, optometry, and veterinary medicine arecomparable. There is a loan program through Scotiabankto assist those who need financial help to attend the pro-gram. The IPG program is also considering distance andpart-time options for international pharmacy graduateswho cannot complete a full-time program in Toronto. Amore flexible program may allow some people to earnincome while completing the program. You may wish tocontact the IPG program to get more specific informationabout future plans for program delivery.

REGISTRATION

QA& Chris Schillemore, R.Ph., B.Sc.Phm.M.Ed.Manager, Registration Programs


Competencies contribute to the definition of a professionby articulating the common and essential knowledge,skills, abilities and attitudes necessary of individuals

engaged in the role. They are also important in supporting theregulation of a profession. The NAPRA document will serve asa foundational document, along with the national educationaloutcomes, (developed by the Canadian Pharmacy TechnicianEducators Association) to support the national accreditation stan-dards for pharmacy technician educational programs (developedby the Canadian Council of Accreditation of Pharmacy Programs)and the entry-to-practice examination for pharmacy technicians(being developed by the Pharmacy Examining Board of Canada).The combination of these documents and processes work togetherto help ensure that individuals are informed of, prepared andqualified to function in the full scope of the role when they enterpractice.NAPRA used the Ontario Competency Profile for Pharmacy

Technicians (published in 2003) as one of several reference doc-uments in the development of the national profile. It is there-fore not surprising to see that the NAPRA profile is very consis-

National PharmacyTechnician Competencies

DEFINING THE SCOPE OF THE PROFESSION AT ENTRY-TO-PRACTICE

The National Association of Pharmacy Regulatory Authorities (NAPRA)

published Professional Competencies for Canadian Pharmacy Technicians

at Entry to Practice in September 2007, and in December, the Council of

the Ontario College of Pharmacists adopted this document for use in

Ontario. These two events are important in helping to advance the

development of this new self-regulating profession.


tent with Ontario’s. While there are somedifferences between the two documentsthey are minimal and relate to the use ofupdated language and increased emphasison patient safety. The role defined by thepharmacy technician competencies recog-nizes the need for a collaborative relation-ship with the pharmacist to support their expanding rolein medication management and drug therapy withpatients, caregivers, physicians and other health careproviders.The College’s adoption of the NAPRA competencies

supports a common national vision for regulation of theprofession. While national agreement of the role, educa-tion and preparation of pharmacy technicians is ideal, itis also important to recognize that regulation of the pro-fession is a provincial responsibility and legislativeapproaches may vary from province to province. Similarly,each place of employment will continue to have theauthority to establish the specific role and function forpositions in their workplace and even though the knowl-

edge, skill and ability of each pharmacytechnician entering the profession willbe consistent, the actual job may bedefined differently across work places.National dialogue is also occurring on

aspects of the regulation initiative. Efforts todevelop common entry-to-practice requirements

and transition processes are ongoing. Current activitiesinclude consideration of common bridging education pro-grams and practical training requirements. The Collegealso anticipates development of national Standards ofPractice, another important document that will serve todefine the expectations of the role further. Ontario pub-lished Draft Standards of Practice for Registered PharmacyTechnicians in January 2005 and will work on finalizingthis document in concert with national efforts. Furtherinformation and consultation will be provided as workprogresses. In preparation for the next steps, individualsmay access the national competency document on theCollege website (www.ocpinfo.com) under the pharmacytechnician section.

Correction:“Buprenorphine – Impact on Pharmacy” Q&A, appearing on page 37 of the January 2008 issue of PharmacyConnection, incorrectly listed the telephone number for the Addiction Clinical Consultation Service at CAMH.Note also, the website to access for suboxone training is www.suboxonecme.caQuestions regarding any clinical issues on buprenorphine or methadone should be directed to1-888-720-ACCS (2227).Questions related to regulatory oversight should be directed to the College’s Professional Practice department.


CASE 1

Discipline of a member both inhis personal professional capacityand as holder of Certificate ofAccreditation for the pharmacyregarding operational deficien-cies, failure to keep records, etc.

Member: Gilbert RosePharmacy: Old Park PharmacyHearing Date: August 21, 2007

FACTSMr. Rose was the owner and desig-nated manager of Old Park Phar-macy (“the Pharmacy”) in Toronto.The College conducted inspectionsof the Pharmacy in February 1999,December 1999, April 2002 andNovember 2003, and identified vari-ous problems with the operation ofthe Pharmacy and Mr. Rose’s prac-tice of pharmacy.Mr. Rose provided action plans

to address the problems identifiedin the inspection reports; despitethese action plans, the same issuescontinued to be identified at thePharmacy.Following the inspection of the

Pharmacy in November 2003, theRegistrar appointed an investigatorto investigate Mr. Rose’s practice.Ultimately there were several refer-rals to the Discipline Committee:specified allegations of Mr. Rose’sprofessional misconduct, by theExecutive Committee, and thePharmacy’s breaches of the Drugand Pharmacies Regulation Act, by

the Accreditation Committee.Subsequently, the Executive

Committee referred additional alle-gations of professional misconductagainst Mr. Rose with respect toincidents in November 2005 andNovember 2006, in which an inves-tigator and an inspector weredenied access to the Pharmacy.The issues identified in the

inspection reports and the Phar-macy’s prescription records includeddirty premises, incomplete referencelibrary, improper storage of regu-lated drugs, dispensing discrepan-cies and recordkeeping deficiencies.Mr. Rose acknowledges that theseproblems should not have occurred,and certainly should have been rec-tified (and never have recurred)once they were brought to hisattention.There were other specific issues:

• Faxed prescriptions at the Phar-macy had been trimmed, contraryto the standards of practice anddespite counselling by Collegeinspectors regarding this practice.

• Mr. Rose had dispensed a brand-name drug without documentingthat he had informed the patientof the availability of a (less expen-sive) generic drug product.

• Prescriptions had been “piggy-backed,” thus creating a falseaudit trail and increasing thechance that an error would bemade if the new prescription var-ied from the old one in any way,again despite counselling by Col-lege inspectors about the prob-

lems with this practice.• Narcotic and non-narcotic pre-scriptions were not cross-refer-enced, as required by the NarcoticControl Regulations.

• Mr. Rose dispensed Demerol to apatient known to him on the basisof a part fill remaining on an ear-lier prescription, specifically onewritten 2 ½ years earlier, despitethe fact that the Pharmacy nolonger possessed the records ofthe original authorization.

• Mr. Rose, over a 20-monthperiod, dispensed Oxycontin to apatient known to him (who hap-pened to be a physician) ten timesmore frequently than the direc-tions for use indicated. Mr. Roserelied on the patient’s reassur-ances rather than intervening andchecking this unusual frequencywith the prescribing physician,which would have revealed thatsome of the prescriptions were, infact, forged.

• Mr. Rose dispensed prescriptiondrugs to two patients in MiamiBeach, Florida, between January2003 and November 2004. Theseprescriptions were issued by USphysicians, co-signed by Ontariophysicians, and faxed to the Phar-macy. Mr. Rose was counselled byCollege inspectors in November2003 that this practice (dispens-ing with the knowledge that therewas no proper physician-patientrelationship between the co-sign-ing physician in Ontario and thepatients in Florida) contravened

DISCIPLINEDECIDING ON


the College’s Policy RespectingOut-of-Country Prescriptions,datedJanuary/February 2003, but hecontinued the practice until thedate of the College investigationin November 2004.

• Despite the legislated requirementto retain pharmacy records fortwo years, Mr. Rose could notprovide records regarding the UStransactions when requested to doso within the two-year period. Mr.Rose reported that he kept theserecords separate from his otherrecords and that he believes thatthey may have been destroyed as aresult of a fire in the neighbour-ing premises.

• Several Schedule II drugs, whichcan be sold only by a pharmacist,were stored in areas of the phar-macy to which the public had fullaccess. This problem was broughtto Mr. Rose’s attention in all threeinspections.Pharmacy staff denied access to

the Pharmacy to a College investi-gator in November 2005, and a Col-lege inspector in November 2006.Mr. Rose was not present at thesetimes and did not direct his employ-ees to refuse access to College staff;however, the College had written tohim after the November 2005 inci-dent, reminding him of the legisla-tion granting investigators andinspectors access to pharmacies,and directing him to educate hisemployees regarding this issue.Therefore, Mr. Rose was responsi-ble for his employees’ continued

refusal to allow College representa-tives to inspect the Pharmacy.

ADMISSIONS OFPROFESSIONALMISCONDUCTMr. Rose admits that he failed tomaintain the standards of practiceof the profession , that he failed tokeep records as required respectinghis clients, that he breached sec-tions 155 and/or 156 of the Drugand Pharmacies Regulation Act, andsections 72 and/or 73 of Regulation551, that he contravened sectionsC.01.041 and/or C.01.042 of theFood and Drug Regulations, and/orsection 31 of the Narcotic ControlRegulations, and that he engaged inconduct or performed an act rele-vant to the practice of pharmacythat, having regard to all the cir-cumstances, would reasonably beregarded by members of the profes-sion as disgraceful, dishonourable,or unprofessional.Mr. Rose admits that the Phar-

macy was operated in contraventionof sections 155 and/or 156 of theDrug and Pharmacies RegulationAct, and section 72 and/or 73 ofRegulation 551, with respect to theincidents identified in the Phar-macy Inspection Reports betweenFebruary 1999 and November 2003

REASONSThe Panel accepted the Joint Sub-mission on Penalty made by theparties. Although Mr. Rose had noprior disciplinary record and good

standing in the community as apharmacist, the Panel did not agreethat misconduct was solely “admin-istrative” in nature. Any time defi-ciencies are detected with respectto narcotic and controlled sub-stances, in particular, the matter isconsidered to be serious. Mr. Rose’smisconduct went on for some timedespite early intervention by theCollege to correct the noted defi-ciencies in Mr. Rose’s practice andOld Park Pharmacy’s operation.

ORDER• A reprimand• Specified terms, conditions, andlimitations on Mr. Rose’s Certifi-cate of Registration, and in partic-ular:o that he complete successfully,at his own expense, within 16months of the date of thisOrder, the following coursesand evaluations:• the Advanced ProfessionalPractice Labs, AdvancedCommunication Skills(including Patient Care Skillsbut not Standardized PatientScenarios), Law Lesson #2(Regulation of PharmacyPractice), Law Lesson #4(Standards of Practice) andLaw Lesson #7 (ProfessionalLiability), all from the Cana-dian Pharmacy Skills Pro-gram offered through theLeslie Dan Faculty of Phar-macy at the University ofToronto; and


• the Jurisprudence seminarand evaluation offered by theCollege; and

o that, if he fails to completesuccessfully the remedialtraining exercises specified inparagraph 2(a) above, his Cer-tificate of Registration be sus-pended, with the suspensionto commence on December21, 2008 and to continue untilsuch time as he can provideproof to the Registrar that hehas successfully completed theremedial training exercisesdescribed in paragraph 2(a)above.

• A suspension of his Certificate ofRegistration for a period of threemonths, with two months of thesuspension to be remitted on con-dition that he complete the above-noted remediation.

• Costs to the College of $20,000.

REPRIMANDWe as a panel are very disappointedthat your past conduct would causeyou to appear before us today. Wewould expect that someone withyour experience would recognizeeven more so, the importance ofour Regulations and Standards ofPractice and how they are designedto ensure the safety of your cus-tomers and the public in general.Under the circumstances, we

feel that it is fortunate that yourmisconduct did not lead to moreserious issues. I trust that you havelearned from these proceedings,

that you will make the appropriatecorrections to your practice andthat we won’t see you back hereagain.

CASE 2

Communication with patients forthe purpose of soliciting business;offering or distributing, directlyor indirectly, a gift, rebate, bonusor other inducement with respectto a prescription or prescriptionservices

Member:Mona YacoubPharmacy: Zehr’s Drug Store Phar-

macy, St. CatharinesDate: December 14, 2007

FACTSMs. Yacoub became the designatedmanager of the pharmacy in late2005 when her predecessor left toestablish his own pharmacy nearby.Ms. Yacoub estimated that in

the first seven months of hertenure, some 800 to 1,000 of herpatients had their files transferredto the new pharmacy. Some of thesepatients were eligible for prescrip-tion drug coverage through theOntario Drug Benefit (“ODB”)Plan. Every August, those patientswould have to pay to the pharmacythe first $100 of the cost of theirprescription medications, as adeductible, before their ODB cover-age began.In August 2006, the College

received the first of eight com-

plaints from ODB patients whowere patients or former patients ofMs. Yacoub and Zehrs. Four ofthese complaints were submitteddirectly by Zehrs’ former designatedmanager (the owner and designatedmanager of the new pharmacy), andanother three of the complaintswere written or facilitated by him orhis staff.The complaints concerning

seven of the Complainants werethat in or about July and August2006, Ms. Yacoub and/or Zehrs’staff had contacted them andoffered to waive the deductible ifthey would transfer their prescrip-tion business back to Zehrs for theentire ODB fiscal year. The com-plaint in respect of the other patientwas that Ms. Yacoub had threatenedto initiate collection proceedingsagainst him for the recovery of hisdeductible that Zehrs had previouslywaived.

ACKNOWLEDGEMENT OFPROFESSIONALMISCONDUCTMs. Yacoub admitted that she didoffer to waive the deductible forcertain of her patients and formerpatients. She stated that this wasdone because she was concernedabout the pharmacy’s loss of busi-ness, and that she had heard thatthe new pharmacy was waiving thedeductible for its clients. Ms.Yacoub stated that she had receivedhead office approval to offer towaive the deductible, as a way of


retaining patients in the future, andof thanking patients who had stayedat Zehrs during the transitionbetween designated managers.Ms. Yacoub did not agree that in

all cases she or her staff had initi-ated the communication with thepatients. But she agreed that thiswas immaterial to the question ofher professional misconduct.With respect to communicating

to a patient that collection pro-ceedings would be commenced forrecovery of the deductible amount,Ms. Yacoub stated that she hadbeen following the advice of hercorporate supervisor. Zehrs hadwaived his payment of thedeductible, but sought to have itrepaid when he transferred his pre-scriptions to the new pharmacy. Infact, that patient had two privateinsurance plans that would cover allof his prescription costs, includingco-payment fees. Therefore, he hadnever needed or requested Zehrs towaive his deductible, and so herefused to re-pay it.Ms. Yacoub admits that she

committed acts of professional mis-conduct with respect to communi-cations with patients or formerpatients Ms. Yacoub and/or staffmembers under her direct supervi-sion communicated with patients orformer patients and offered to waivethe deductible as an incentive tohave them fill their prescriptions atZehrs, offered or distributed,directly or indirectly, a gift, rebate,bonus or other inducement with

respect to a prescription or prescrip-tion services, and in one case toldaformer patient that Zehrs wouldtake collection action against him.Ms. Yacoub admits that this con-duct would reasonably be regardedby members of the profession asunprofessional.

REASONSThe panel made findings of profes-sional misconduct further to Ms.Yacoub’s acknowledgement andplea, and accepted the Joint Sub-mission on Penalty made by the par-ties.The panel noted that Ms.

Yacoub was under pressure to stopor slow down the exiting of Zehrspatients following the departure ofthe former designated manager.However, in doing so she hadimpermissibly crossed the linebetween pharmacist as health careprofessional and pharmacist as busi-ness person.The rules of professional mis-

conduct are clear on the issue ofloyalty programs, inducements, anddirect solicitation of targetedpatients. Ms. Yacoub was responsi-ble for this misconduct, eventhough she had sought and receivedhead office approval for her plan.The panel noted in mitigation

that there had been no previouscomplaints against Ms. Yacoub, thatshe had cooperated fully with theCollege in its investigation, and thatshe had shown remorse and regretover what had occurred.

ORDER1. A reprimand.2. Specified terms, conditions orlimitations on Ms. Yacoub’s cer-tificate of registration, and inparticular, that she complete suc-cessfully, at her own expense,within six months, the followingcourses and evaluations:(a) The Jurisprudence seminarand evaluation offered bythe College; and

(b) Law Lesson 2 (Regulationof Pharmacy Practice), LawLesson 4 (Standards ofPractice) and Law Lesson 7(Professional Liability) fromthe Canadian PharmacySkills Program, offeredthrough the Leslie DanFaculty of Pharmacy at theUniversity of Toronto.

3. A suspension of Ms. Yacoub’sCertificate of Registration for aperiod of two months, with onemonth of the suspension to beremitted on condition that shecomplete the remedial trainingexercises specified above.

4. Costs to the College in theamount of $5,000.00.

REPRIMANDThe panel reminded Ms. Yacoubthat as a member of a professionshe enjoyed certain privileges, andin turn had significant responsibili-ties. As such, she had obligationsseparate and distinct from her roleas a commercial business operator.In this instance she had let the


commercial operations of the busi-ness of pharmacy override her pro-fessional responsibilities, and as aresult had fallen below the stan-dards expected of her as a practic-ing professional pharmacist, andthereby committed acts of profes-sional misconduct.The panel stated that there will

always be challenges in balancingthe professional and commercialrequirements of pharmacy practiceand the financial expectations ofones employer. In all cases the pro-fessional responsibility must prevail.As a front line pharmacist and des-ignated manager Ms. Yacoub wasrequired to know and meet thestandards of professional practice.The panel noted that Ms.

Yacoub had accepted responsibilityfor her actions and had demon-strated remorse for the activitiesthat had brought her before thepanel. She had also cooperated withthe College in this process.The panel believed that the

remediation included in the penaltywas important.The panel was disturbed by the

fact the Ms. Yacoub’s employerappeared to have approved and con-doned her misconduct, but notedthat in the final analysis sheremained professionally responsiblefor it.The panel hoped that Ms.

Yacoub had learned from her lapseof judgement and would use this asan opportunity to become a betterprofessional.

CASE 3

Member: Virginia HungPharmacy: Upper James Centre

Pharmacy, HamiltonDate: November 14, 2007

FACTSMs. Hung owned and managed thepharmacy, and practiced there as adispensing pharmacist. On five sep-arate occasions between June andSeptember 2006, Ms. AJ attendedthe pharmacy with a prescriptionfor Cyclophosphamide 25mg. Ms.AJ had been diagnosed with earlystage, high risk breast cancer, andthis was one of the drugs that hadbeen prescribed as part of a courseof chemotherapy treatment for her.Each of the five prescriptions

listed multiple medications on an 8-1/2 by 11” computer-generatedprintout which clearly identified thedrug, dose, route of administration,quantity, refill (where applicable),instructions and comments. Withregard to the Cyclophosphamidemedication, each of the prescrip-tions prescribed 98 tablets with norefills and instructions to “Take175mg. every morning for 14 days.”The prescriptions also included thefollowing recommendation regard-ing this drug: “Use Procytox Brandfor Better Patient Tolerance.”Ms. Hung was the dispensing

pharmacist on each of these occa-sions. Instead of dispensingCyclophosamide, she dispensedCyclosporine 25mg to Ms. AJ.

Cyclosporine is not a drug used inthe treatment of cancer, but ratheran immunosuppressant used totreat organ transplant patients. It isa potentially nephrotoxic drug thatcan cause liver damage, and it alsointeracts with two of the other med-ications that had been prescribedfor Ms. AJ as part of her course ofchemotherapy treatment.After Ms. AJ’s third cycle of

chemotherapy was administered,she was hospitalized for anemia,dehydration and hypotension. Shewas subsequently stricken with neu-tropenia, a condition that interfereswith the body’s ability to fight acutebacterial and fungal infections.After the fifth cycle of chemother-apy, the dispensing error was discov-ered. One of Ms. AJ’s physiciansattributed the above-noted debilitat-ing symptoms to her ingestion ofCyclosporine and her failure toreceive the proper Cyclophos-phamide. The physician filed a for-mal complaint with the College.

ACKNOWLEDGEMENT OFPROFESSIONALMISCONDUCTMs. Hung stated that at the time ofthe first dispensing error in June2006, she was under considerablestress due to her mother-in-law’sserious illness. The subsequenterrors occurred while she was griev-ing over her mother-in-law’s death.Ms. Hung also stated that she hadintroduced new procedures at thepharmacy to address the problems


associated with the dispensingerrors, and that she had attendedthe Ontario Pharmacy Associationcourse “Confronting MedicationErrors” in March 2007.Ms. Hung acknowledged that

the conduct described above consti-tuted professional misconduct onher part as the owner and desig-nated manager of the pharmacy,and in her capacity as the dispens-ing pharmacist. In particular, sheacknowledged that she failed to takeadequate, or any, steps to ensurethat the medication she dispensedwas the medication that had, infact, been prescribed for Ms. AJ andthat she had therefore failed tomaintain a standard of practice ofthe profession, breached regulationsof the Drug and Pharmacies Regu-lation Act and engaged in conductrelevant to the practice of pharmacythat could reasonably be regardedby members of the profession in allof the circumstances as disgraceful,dishonourable or unprofessional.In connection with a previous

dispensing error, Ms. Hung hadreceived a written caution from theComplaints Committee in Septem-ber, 2006. It had cautioned her toensure that “the correct medicationis dispensed to the correct patientin the correct dosage as per theinstructions of the prescribingphysician,” and reminded her toexercise “care and mindful atten-tion” when dispensing medications,and that “there is no room for errorin the practice of pharmacy and

that accuracy is paramount in allaspects of the dispensing process.”

REASONSThe patient was at the forefront ofthe panel’s mind. The panel notedthat Ms. AJ brought the same pre-scription into Ms. Hung’s pharmacyon five separate occasions, and thatshe had received the wrong medica-tion even though opportunitiesexisted for Ms. Hung to interactwith Ms. AJ to prevent such anerror.Given the seriousness of Ms.

AJ’s illness, her presumed state ofmind, and the nature of the pre-scribed medication, the panel wouldhave expected Ms. Hung to exercisea heightened level of scrutiny indealing with this situation.Ms. Hung, as a pharmacist, is

ultimately responsible to ensurethat all medications are properlyand accurately dispensed, notwith-standing that a pharmacy techni-cian may have a role in processingthe prescription. Appropriate proce-dures and checks must exist withina pharmacy setting amongst thepharmacist and their staff, with thepharmacist having final approvalbefore a prescription is dispensed toa patient. In this case, since eachprescription was written as a newprescription, it should have beenconsidered as such. The panelnoted that Ms. Hung should havebeen especially careful in light ofher previous dispensing error.The panel made a finding of

professional misconduct andaccepted the parties’ Joint Submis-sion on Penalty, believing that thepenalty was appropriate in light ofthe other cases presented as prece-dents. In particular, believed thatthe course work be of great benefitto Ms. Hung in preventing thesetypes of errors.

ORDER1. A reprimand.2. Specified terms, conditions or lim-itations on Ms. Hung’s Certificateof Registration and, in particular,that she complete successfully, ather own expense, within twelvemonths, remedial training as fol-lows:a. Basic Professional Practice LabsI, including evaluations, offeredthrough the Leslie Dan Facultyof Pharmacy at the Universityof Toronto, as follows:i. Module 3 – Basic ProfessionalPractice Laboratories; and,

ii. Module 4 – Patient Coun-selling Skills.

3. A suspension of Ms. Hung’s Cer-tificate of Registration for a periodof two months, with one month tobe remitted upon successful com-pletion of the remedial trainingexercises specified above.

4. Cost to the College in the amountof $3,000.00.

REPRIMANDThe Panel was very concerned thatthis type of error occurred on fiveseparate occasions when there were


clearly five independently computergenerated prescriptions. Furthermore,each prescription contained enoughtherapeutic clues, including thebrand name of the drug, that shouldhave alerted Ms. Hung that the med-ication being dispensed was incorrect.Ms. Hung had neglected appro-

priate checks and procedures,including dialoguing with the

patient, and had thus failed to meetthe profession’s standards of prac-tice, and caused very significant dis-pensing errors. The panel was dis-turbed that a preventable error ofthis nature had been replicated onmultiple occasions.The panel was encouraged that

Ms. Hung had taken some steps tocorrect her practice deficiencies

through remedial training. Thepanel trusted that the further reme-dial courses agreed to would resultin practices that comply with thestandards of this College.The panel urged Ms. Hung to

seriously reflect on what hadoccurred, and to determine whatother personal steps she needed totake to prevent future errors.

February 18, 2008

The National Drug Scheduling Advisory Committee (NDSAC) was established by the National Association of PharmacyRegulatory Authorities (NAPRA) in 1995. It was formed to advise provincial pharmacy regulatory bodies as well asgovernments at the provincial and federal levels, on matters related to the conditions for sale of drugs in Canada.

NDSAC’s eight expert members are chosen for their knowledge and experience in such disciplines aspharmacotherapy, drug utilization, drug interactions and toxicology, pharmacy practise, academic research, the drugindustry and pharmaceutical regulatory affairs at provincial and federal levels.Appointments of expert members are not representational in nature, and NDSAC expert members may not promotethe views of any business, organization or association. Committee members must declare any real or perceivedconflicts of interest, and adhere to strict confidentiality codes.

There are currently two specific vacancies on the committee:1. an individual with expertise in drug policy and safety issues from the perspective of pharmaceutical regulatoryaffairs at the provincial or federal government levels, and

2. an individual with expertise in the area of toxiciology related to pharmaceuticals.

The NAPRA website (www.napra.org) has detailed information about the committee and the drug scheduling process.For further information, contact BarbaraWells, NDSAC Secretariat by e-mail at [email protected]; telephone at 613-233-0348, or fax at 613-233-0343.

Nominations with resumesmust be received (by email or fax) no later than Friday, April 4th, 2008.

RECRUITMENT NOTICE

National Drug SchedulingAdvisory Committee



This edition of ISMP Canada Safety Bulletin is reproduced with permission from Institutefor Safe Medication Practices Canada.

To order a free subscription, visit: www.ismp-canada.org/subscription.htmand simply fill out and submit the form.

Summary of circumstancesMr. G. S., age 46 attended a methadone clinic at approx-imately 4pm on Feb2, 2004, where he had been attend-ing for 2 months. Although he smelled of alcohol, he didnot seem to be intoxicated and he received a prescriptionfor his usual dose of methadone 40mg and proceeded tothe pharmacy where he received his methadone under thesupervision of the pharmacist and left. At approximately522pm he was found lying in a snow bank. Police helpedhim up, and arrested him for his own protection for beingintoxicated in a public place, as they were concerned abouthim surviving in the cold weather. He denied that he wastaking any medication. At 811pm he was found with novital signs, given CPR, and transported to hospital wherehe was pronounced dead. Toxicology revealed a high bloodalcohol concentration as well as methadone in his blood.The cause of death was attributed to the combined toxiceffects of methadone and ethanol.As a result of the coroner’s inquest into this death,

the following recommendations were made to the OntarioCollege of Pharmacists

• Review the current policies on assessing for alcoholand consider adding the requirement that every phar-macy that dispenses Methadone in Ontario beequipped with means to test Blood Alcohol (BAC) byway of breathalyser or similar instrument to assist phar-macists assessing clients intoxication prior to dispens-ing Methadone.

• Circulate the verdict and recommendations of thisCoroners jury to all pharmacies that dispenseMethadone with a view to reinforcing to those phar-macies and pharmacists the importance of assessingevery patient for intoxication prior to dispensingMethadone.

Rationale: The Ontario College of Pharmacists refers tothe practice of utilizing breathalysers to assist in assess-ing intoxication but does not require pharmacists toinclude this type of testing. The Ontario College of Phar-macists, after appropriate study, should provide directionto their members in this regard. Assessing a client’s levelof intoxication is very difficult and possibly imprecise onthe basis of physical observations. Breath testing for thepresence of alcohol could be extremely helpful to assistpharmacists in assessing intoxication prior to dispensingMethadone. All pharmacists should be reminded of thecontinuing importance of not providing Methadone tointoxicated patients given the tragic consequences toMr.G.S. arising from the combined consumption ofMethadone and alcohol.

Coroner’s Comments: the jurors heard evidence thatthe combination of Methadone and alcohol could causesignificant respiratory depression and, as in this case,death. People who are intoxicated by alcohol may ormay not demonstrate outward signs of intoxicationdepending on their tolerance. It was shown that Mr.

This report and accompanying information is presented to reinforce to pharmacists the importance of carefully assessingeach patient before administration of methadone.


CORONER’S REPORTCORONER’S REPORT

CombinedToxic Effects ofMethadone and Ethanol

Extracted from the verdict and recommendations of the Coroner’s Jury from the inquest into the death of G.S. June 2007.


G.S. had a very high level of alcohol in his blood withno significant outward signs of intoxication, but he didsmell of alcohol. In these recommendations, I believethat the jury did not intend for every person to be testedfor alcohol but only those clients who had an odour ofalcohol about them. The jurors wanted to emphasizethe importance of assessing patients for possible previ-

ous alcohol ingestion prior to the provision ofMethadone. The jury clearly understood that a clientcould ingest methadone, and then proceed to drink alco-hol afterwards. While this is possible, I believe thatthey felt that at least one method of combining the twosubstances could effectively be eliminated utilizing thisstrategy.

TheOntario College of Pharmacists has reviewed the above recommendationsmade by the Coroner’s Jury. Althoughsomepharmacists, in collaborationwith physiciansmay use breathalysers for certain patients in certain situations, it isnot reasonable for every pharmacy to have a breathalyser to test for alcohol levels. Other central nervous systemde-pressants (ie. Benzodiazepines) also cause impairment and are equally dangerous in combinationwithmethadone.There is also concern that breathalyser readingsmay not be conclusive in evaluating impairment, depending on indi-vidual tolerance, so that an acceptable breathalyser reading could not be relied onwithout assessing patientsymptoms.However, the pharmacist’s assessment for a patient’s possible symptoms of intoxication is critical before each dose ofmethadone is administered. In all caseswhere the pharmacist detects any unusual symptoms or behaviours, the deci-sion to either give orwithhold a dose ofmethadone should be documented.The following guidelines regarding intoxicated patients are reprinted from the Center for Addiction andMental Health(CAMH) guidelines, chapter onDispensing andObserved Self-Administration.

Intoxicated Patients• All patientsmust be assessed for intoxication prior tomedicatingwithmethadone.• Assess for symptoms such as slurred speech, ataxia, drowsiness, the smell of alcohol or unusual behaviour. To testalcohol levels, some pharmacies have breathalysers that they usewith the agreement of the prescriber. If levelsabove a certain threshold are detected, for example, 30 or 50mg%,methadone is not dispensed until the alcohollevel has fallen below that threshold.

• If the patient is intoxicated,medicating should be deferred until the patient has been reassessed and found to nolonger be impaired. Despite the possibility of a patient experiencing some opioid withdrawal symptoms, it is safer todelaymedicating or refuse tomedicate an intoxicated patient. Opioid withdrawal is not life threatening, but addingmethadone to the others drugs already consumed by an intoxicated patientmay be.

• Try to avoid confrontationwith the patient by explaining that it would be dangerous tomedicate at this time. If phar-macy hours allow, invite the patient to return later, at which time it might be possible to dispense themethadone.

•Warn the patient against driving a car.• Inform the prescriber that the patient appeared intoxicated in your pharmacy.• Clearly document your actions.


F O C U S O N

addition of an incorrect diluent.

Pharmacists regularly reconstitute oral antibiotic sus-pensions prior to dispensing by adding water to thedrug powder. Unfortunately, there have been reports

of errors involving the addition of an incorrect diluent.In one reported case1, a four and a half year old boy

was prescribed amoxicillin suspension. The pharmacy inwhich the antibiotic was dispensed was a dispensing cen-tre for a methadone maintenance program. Instead ofwater, methadone stock solution was accidentally mixedwith the antibiotic.In another case, an eighteen month old child was pre-

scribed azithromycin suspension. The pharmacy useddistilled water from a four litre stock bottle when recon-stituting most antibiotics. However, due to the smallquantity of water required to reconstitute a bottle ofazithromycin suspension (9 ml in this case), the phar-macy used a 500 ml bottle to create a smaller stock bot-tle of distilled water. An oral syringe with an adapter wasthen inserted into the opening of the bottle to withdrawthe required amount of water.The pharmacy also stocked a 500 ml bottle of ethanol

which was used for compounding Benzamycin® topicalgel. Similarly, an oral syringe with adapter was insertedinto the opening of the bottle and used to withdraw thesmall quantity of ethanol required.On this occasion, when reconstituting the

azithromycin suspension, the pharmacy technician inad-vertently selected the ethanol stock bottle, withdrew 9 mlethanol and added it to the azithromycin powder. Thepharmacist checked the prescription but was unaware ofthe error. After receiving appropriate counseling, thefather left the pharmacy with the incorrectly reconsti-tuted antibiotic.

On arriving home, the father opened the bottle ofazithromycin and found very little liquid due to the evap-oration of the ethanol. The father therefore returned tothe pharmacy and reported that “something must bewrong because it is not possible to give five doses fromthis bottle.”Assuming that an incorrect quantity of water was

added to the dry powder initially, the pharmacist askedthe pharmacy technician to reconstitute another bottleof azithromycin suspension. On this occasion, the phar-macist decided to check the quantity of water being addedby the technician. To the pharmacist’s surprise, the tech-nician selected the stock bottle of ethanol. Upon ques-tioning the technician, she acknowledged that she didindeed use ethanol liquid to reconstitute the first bottleof azithromycin suspension. Fortunately, the father didnot administer any of the ethanol containing antibioticto the child.

Possible Contributing Factors:

• Both distilled water and ethanol were stored in darkcoloured 500 ml bottles.

• Ethanol and distilled water are similar in appearanceand viscosity.

• A second technician used the ethanol stock solutionearlier to compound Benzamycin® topical gel and didnot return the ethanol solution to its usual storage loca-tion. Instead, it was left on the pharmacy counterwhere the distilled water was usually stored.

• Reconstitution of antibiotics and extemporaneous com-pounds occurred in the same area of the pharmacy.

Recommendations:

• Use distilled water from its original container which isclearly labelled.

• Never use empty distilled water containers to store otherclear liquids such as alcohol, formalin or methadonestock solution.

• Check your pharmacy to ensure that similar bottles arenot used to store two different liquids. Ensure that allstock bottles are clearly labelled. Attach a colouredsticker if necessary to assist in differentiation.

• Store potentially lethal solutions such as methadone

Ian Stewart, R.Ph., B.Sc.Phm.Practising Community Pharmacist in Toronto

Error PreventionError Prevention

Planning is underway for a 20th anniversaryreunion of the Class of 8T8 to be held theweekend of April 19, 2008 in Niagara onthe Lake. Please contact Jane at [email protected] or Heather [email protected]

The Golden Tea Dinner for the Classof 5T8 will be held on Saturday, May31st at the Faculty Club at the University ofToronto. A tour of the Leslie Dan PharmacyBuilding and other alumni activities are also beingplanned. For more information, contact Sam Hirschat 416 399 4524 or Miriam Stephan, pharmacyalumni affairs officer at 416 946 3985.

The College said farewell to Lisa Baker, HumanResources Coordinator, who left the College in Janu-ary to pursue an opportunity with World Vision. TheCollege thanks Lisa for her contributions and wishesher well in this new venture.

In early February, Shakti Sawh joined the College asPractice Advisor. Shakti completed the College’s Certi-fied Pharmacy Technician examination and has experi-ence in both retail and hospital pharmacy. Shakti hastaught and been involved in curriculum developmentfor community college technician programs and is cur-rently working on her Bachelor’s Degree in Education.

Lucy Wang joined the College’s accounting teamto fill a maternity leave. Lucy has a diplomain Business Administration, with a major inAccounting, and is pursuing her CertifiedGeneral Accountant designation. Herwork experience includes accountsreceivable, accounts payable and accountreconciliation.

Catherine McCormick has been hired intoan Administrative Assistant position in the Investi-

gations and Resolutions Program department whereshe will be working along with the I&R team to sup-port the complaints and investigations processes.Catherine obtained her Bachelor of Arts in Communi-cations in Florida and has worked in a variety ofadministrative capacities.

Eugene Onutan recently joined the College in a con-tract position as a web developer for InformationTechnology Services. Eugene came to us from YorkUniversity with more than ten years experience in pro-gramming and web development.

Celebrating Innovations in Health Care Expo2008, Tuesday, April 22, 2008. Metro Toronto Con-vention Centre. To apply and/or register visitwww.health.gov.on.ca/innovations

B U L L E T I N B O A R D


stock solution in unique, distinguishable containers.• Return stock bottles to their storage locations immedi-ately after use.

• Consider investing in an electronic water dispensingsystem thereby eliminating the need for a stock bottleof water.

Reference:1. Lalkin A, Kapur BM, Verjee ZH, Koren G, Contami-nation of antibiotics resulting in severe pediatricmethadone poisoning. Ann Pharmacother. 1999Mar;33(3):314-7.

Please continue to send reports of medication errors inconfidence to Ian Stewart at: [email protected]


C E E V E N T SVisit 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

March 30, 2008Methadone Maintenance Treatment (MMT)ClassroomWorkshopCentre for Addiction and Mental HealthContact: Rosalicia RondonTel: 416-535-8501 x 6658Email: [email protected]: www.camh.net

Part I April 2, 3, 4, 2008Part II online May through August, 2008Part III September 10, 11, 12, 2008Advanced Cardiology Pharmacy PracticeContact: Jessy BalendraEmail: [email protected]: 416-946-0660Web: http://cpd.phm.utoronto.ca

April 17 – 18, 2008Patient SafetyContact: Karine GeorgesEmail: [email protected]: 416-205-1347

April 25 - 27: Toronto2008 Pain and Palliative Care - Level 1 CertificateProgramContact: Penny YoungEmail: [email protected]

May 23 - 25: Toronto2008 Cardiovascular Patient Care - Level 1Certificate ProgramContact: Penny YoungEmail: [email protected]

June: Toronto2008 Diabetes Patient Care - Level 1 CertificateProgramContact: Penny YoungEmail: [email protected]

ONTARIO

March 25, 2008: Kingston, ONMarch 26, 2008: Peterborough, ONMarch 27, 2008: Windsor, ONGuide Your Patients to a Smoke Free FutureContact: Tania AntenucciEmail: [email protected]: 416-441-0788 x, 4232

ONLINE COURSES

Accessing Drug InformationAnticoagulationDiabetesHypertension,University of AlbertaWeb: www.pharmalearn.com

CANADA

May 31 – June 3, 2008: Victoria, BCCanadian Pharmacists Association Annual NationalConferenceWeb: www.pharmacists.ca

INTERNATIONAL

March 14 – 17, 2008: San Diego, USAAmerican Pharmacists AssociationAnnual Meeting and ExpositionTel: 1-877-842-3133Email: [email protected]: www.aphameeting.org


L aws & Regu l a t i o ns - April 2008

Drug and Pharmacies Regulation Act (DPRA) * �Amended 2007Regulations to the DPRA:DPRA R.R.O. 1990, Regulation 545 – Child Resistant PackagesDPRA Ontario Regulation 297/96Amended to O.Reg. 180/99 – GeneralDPRA R.R.O. 1990, Regulation 551Amended to O.Reg. 179/99 – General

Drug Schedules **Summary of Laws Governing Prescription Drug Ordering, Records,PrescriptionRequirements and Refills - June 2007 OCPCanada’s National Drug Scheduling System –December 5, 2007NAPRA (or later)

Regulated Health Professions Act (RHPA) * �Amended 2007Regulations to the RHPA:Ontario Regulation 39/02 -Certificates of AuthorizationAmended toO.Reg. 666/05Ontario Regulation 107/96 – Controlled Acts Amended to O.Reg. 296/04Ontario Regulation 59/94 – Funding for Therapy or Counseling for PatientsSexually Abused by Members

Pharmacy Act (PA) & Regulations * �Amended 2007Regulations to the PA:Ontario Regulation 202/94Amended to O.Reg. 270/04 – GeneralOntario Regulation 681/93Amended to O.Reg. 122/97 – ProfessionalMisconduct

Standards of Practice �Standards of Practice, January 1, 2003 OCPStandards of Practice for Pharmacy Managers, July 1, 2005

Drug Interchangeability and Dispensing Fee Act (DIDFA) & Regulations * �Amended 2007Regulations to the DIDFA:R.R.O. 1990 Regulation 935Amended to O.Reg. 558/06 – GeneralR.R.O. 1990 Regulation 936Amended to O.Reg. 205/96 – Notice to Patients

Ontario Drug Benefit Act (ODBA) & Regulations * �Amended 2007Regulations to the ODBA:Ontario Regulation 201/96Amended to O.Reg. 559/06 – General

Food and Drugs Act (FDA) & Regulations � **Updated as of Dec. 31, 2006Amendment 1478 & 1491 –Addition of two medicinal ingredients to Part I of ScheduleF. Reg. SOR/2007-224, Oct 25/07Amendment 1476, 1502, 1511 and 1512 –Addition of nine medicinal ingredients toPart I of Schedule F. Reg SOR/2007-234, Oct 25/07

Controlled Drugs and Substances Act (CDSA) **Current as of January 14, 2008Regulations to the Controlled Drugs and Substances Act (CDSA) **All regulations updated March, 2007Benzodiazepines & Other Targeted Substances RegulationsMarihuana Medical Access RegulationsPrecursor Control RegulationsRegulations Exempting Certain Precursors and Controlled Substances from theApplication of the Controlled Drugs and Substances Act

Narcotic Control Regulations **Current as of January 14, 2008

OCP By-Laws By-Law No. 1 – December 2007 �ScheduleA - Code of Ethics for Members of the Ontario College of Pharmacists -December 2006Schedule B - "Code of Conduct” and Procedures for Council and CommitteeMembers - December 2006Schedule C - Member Fees - Effective January 1, 2007Schedule D - Pharmacy Fees - Effective January 1, 2007Schedule E – Certificate of Authorization – Jan. 2005Schedule F - Privacy Code - Dec. 2003

Reference �Handling Dispensing Errors, Pharmacy Connection Mar/Apr 1995Revenue Canada Customs and Excise Circular ED 207.1Revenue Canada Customs and Excise Circular ED 207.2Guidelines for the Pharmacists on “The Role of the Pharmacy Technician”OCP Required Reference Guide for Pharmacies in Ontario, June 2007

C O L L E G E S T A F F

Office of the Registrar and Deputy Registrar/Director of Professional DevelopmentPharmacy Connection Editor x [email protected]

Office of the Director of FinanceandAdministration x [email protected]

Office of the Director ofProfessional Practice x [email protected]

Registration Programs x [email protected]

Structured Practical Training Programs x [email protected]

Investigations and Resolutions x [email protected]

Continuing Education Programs andContinuing Competency Programs x [email protected]

Pharmacy Openings/Closings,Pharmacy Sales/[email protected]

Registration andMembership Information:[email protected]

Pharmacy Technician Programs:[email protected]

Publications x [email protected]

* Information available at Publications Ontario (416) 326-5300 or 1-800-668-9938 www.e-laws.gov.on.ca

** Information available atwww.napra.org

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