Medication Errors & Discipline - Ontario College of Pharmacists

ANNUAL PHARMACY FEES DUE MAY 10, 2009 

Profile of the Relief Pharmacist 

page 6 

Ontario’s eHealth Strategy 

page 8 

Medication Errors & Discipline 

page 22

ontario college of pharmacists 

483 Huron Street, Toronto, Ontario M5R 2R4 • Tel (416) 962-4861 • Fax (416) 847-8200 • www.ocpinfo.com 

The mission of the Ontario College of Pharmacists is 

to regulate the practice of pharmacy, through 

the participation of the public and the 

profession, in accordance with standards of 

practice which ensure that pharmacists 

provide the public with quality 

pharmaceutical service and care. 

Council Members 

Council Members for Districts 1-17 are listed below according to District number. PM indicates a public member appointed by the 

Lieutenant-Governor-in-Council. DFP indicates the Dean of the Leslie Dan Faculty of Pharmacy, University of Toronto. 

DSP indicates the Director, School of Pharmacy, University of Waterloo. 

1 Joseph Hanna 

2 Elaine Akers 

3 Sherif Guorgui 

4 Tracey Phillips 

5 Donald Organ 

6 Fayez Kosa 

7 Tracy Wiersema 

8 Saheed Rashid 

9 Bonnie Hauser 

10 Gerald Cook 

11 Christopher Leung 

12 Peter Gdyczynski 

13 Sanjiv Maindiratta 

14 Stephen Clement 

15 Gregory Purchase 

16 Doris Nessim 

17 Shelley McKinney 

PM Joinal Abdin 

PM Thomas Baulke 

PM Corazon dela Cruz 

PM Babek Ebrahimzadeh 

PM David Hoff 

PM Margaret Irwin 

PM Javaid Khan 

PM Lewis Lederman 

PM Aladdin Mohaghegh 

PM Gitu Parikh 

DFP Wayne Hindmarsh 

DSP Jake Thiessen 

Statutory Committees 

• Executive 

• Accreditation 

• Complaints 

• Discipline 

• Fitness to Practice 

• Patient Relations 

• Quality Assurance 

• Registration 

Standing Committees 

• Communications 

• Finance 

• Professional Practice 

Special Committees 

• Standards of Practice Working Group 

• Pharmacy Technicians Working Group 

College Staff 

Office of the Registrar and Deputy Registrar/ 

Director of Professional Development 

Pharmacy Connection Editor x 241 

ltodd@ocpinfo.com 

Office of the Director of Finance 

and Administration x 263 

bhsu@ocpinfo.com 

Office of the Director of 

Professional Practice x 236 

sjackson@ocpinfo.com 

Registration Programs x 250 

jsantiago@ocpinfo.com 

Structured Practical Training Programs x 297 

vgardner@ocpinfo.com 

Investigations and Resolutions x 274 

cfernandes@ocpinfo.com 

Continuing Education Programs and 

Continuing Competency Programs x 273 

lsheppard@ocpinfo.com 

Pharmacy Openings/Closings, 

Pharmacy Sales/Relocation 

ocpclientservices@ocpinfo.com 

Registration and Membership Information: 


Pharmacy Technician Programs: 


Publications x 229 

spark@ocpinfo.com

contents 

Profile of the Relief Pharmacist 6 

eHealth Ontario 8 

Report of the Geriatric and Long Term Care 

Review Committee to the Chief Coroner 10 

ISMP - Medication Safety in Long-Term Care 18 

regular features 

President’s Message 4 

Editor’s Message 5 

Practice Q&A 14 

Health Canada Notices 17 

Pharmacy Technician Q&A 20 

Close up on Complaints 22 

Bulletin Board 23 

SPT Q&A 24 

Deciding on Discipline 25 

Focus on Error Prevention - Ambiguous Prescriptions 28 

CE Resources 29 

Laws & Regulations 31 

pharmacyconnection 

March/April 2009 July • August Volume 200816 • Number Volume 215 • Number 4 

The objectives of Pharmacy Connection are to communicate information on College activities and policies; encourage dialogue and to discuss issues of 

interest with pharmacists; and to promote the pharmacist’s role among our members, allied health professions and the public. 

We publish six times a year, in January, March, May, July, September and November. We welcome original manuscripts (that promote the objectives of the 

journal) for consideration. The Ontario College of Pharmacists reserves the right to modify contributions as appropriate. Please contact the Associate Editor 

for publishing requirements. 

We also invite you to share your comments, suggestions, or criticisms by letter to the Editor. Letters considered for reprinting must include the author’s 

name, address and telephone number. The opinions expressed in this publication do not necessarily represent the views or official position of the Ontario 

College of Pharmacists. 

Tracy Wiersema, R.Ph., B.Sc.Phm. 

President 

Deanna Williams, R.Ph., B.Sc.Phm., C.Dir., CAE 

Registrar 

Della Croteau, R.Ph., B.S.P., M.C.Ed. 

Editor, Deputy Registrar, 

Director of Professional Development 

dcroteau@ocpinfo.com 

Sue Rawlinson 

Associate Editor 

srawlinson@ocpinfo.com 

Agostino Porcellini 

Production & Design / Webmaster 

aporcellini@ocpinfo.com 

Neil Hamilton 

Distribution 

nhamilton@ocpinfo.com 

ISSN 1198-354X 

© 2009 Ontario College of Pharmacists 

Canada Post Agreement #40069798 

Undelivered copies should be returned 

to the Ontario College of Pharmacists. 

Not to be reproduced in whole or in part 

without the permission of the Editor.

president’s message 

Tracy Wiersema, R.Ph., B.Sc. Phm. 

President 

Advocacy vs public interest 

Many members of the College 

get confused about the role 

of the College in advocating 

for the profession. The College has 

been established through government 

legislation to regulate the profession in 

the best interest of the public. As such, 

the privilege of self regulation requires 

that all decisions be guided with public 

safety in mind. Our respective associations 

for hospital and community 

pharmacy, CSHP (Ontario Branch) 

and the Ontario Pharmacists Association, 

on the other hand, speak on behalf 

of, and advocate for the pharmacist and 

the profession. Fortunately, many decisions 

that are in the best interest of the 

public are also in the best interest of the 

profession of pharmacy. 

The current Health Professions 

Regulatory Advisory Committee 

(HPRAC) submissions and reports 

are a good example of both public and 

advocacy interests being met. It is in 

the best interest of the public for pharmacists 

to be able to adapt, extend, 

and modify prescriptions and manage 

medication therapy in collaboration 

with other health care providers. It is 

also in the best interest of the pharmacist 

to take on this expanded role, 

to educate ourselves to provide medication 

therapy management, and to 

expand our role beyond dispensing of 

medications, taking responsibility for 

patient outcomes. 

The role of the College will be to set standards for 

education and practice, and to have a system in place 

to ensure that pharmacists are carrying out these new 

roles safely and effectively for the public... 

If these new expanded roles get approved 

by government and legislation 

is put in place, the roles of the College 

and the advocacy bodies will both be 

important, but different. The role of 

the College will be to set standards for 

education and practice, and to have a 

system in place to ensure that pharmacists 

are carrying out these new roles 

safely and effectively for the public, 

that they are documenting their decisions 

and working collaboratively with 

other health care professionals. The 

job of the advocacy bodies will be to 

promote the best use of the pharmacist, 

encourage and facilitate their education 

and training, and to advocate for 

their role in the workplace, not only 

from a scope and responsibility perspective, 

but also from a monetary 

perspective. Promotion of payment of 

the pharmacist for these new roles will 

be up to the advocacy bodies in hospital 

and community who will represent 

the best interests of the pharmacists. 

Our profession is healthier with 

both strong regulatory and strong advocacy 

bodies. Many of our goals, such 

as excellence in pharmacy practice, 

are aligned but it is important that the 

public interest and the interest of the 

profession be represented by separate 

bodies, and that these roles be clearly 

distinguished for all stakeholders. 

4 pharmacyconnection • March/April 2009

editor’s message 

Della Croteau, R.Ph., B.S.P., M.C.Ed. 

Deputy Registrar/Director of Professional Development 

Many pharmacists tell me 

that when they receive 

Pharmacy Connection, 

they turn right to the discipline cases 

to see who was disciplined and what 

they did wrong. 

In fact, only a very small portion of 

reports and complaints ever go to discipline 

(less than 10%), and there are certainly 

some lessons to be learned by 

reading the discipline cases. 

If you are just reading the discipline 

cases in Pharmacy Connection, you 

are really missing out on all the practice 

information offered to help you continually 

improve your practice. In this 

issue, the chair of the discipline committee 

has written an article to educate 

pharmacists about medication errors, 

and how to manage them so that they 

do not go forward to discipline. The 

College has published several articles 

from the Institute for Safe Medication 

Practices Canada (ISMP) regarding 

Let us know what information is valuable to you, 

and what other ways the College can provide you 

with quality improvement information that 

supports your practice. 

medication incidents and how to prevent 

them. As well the focus on error 

prevention sites common practice 

errors and makes recommendations 

about how to prevent them from happening 

in the workplace. 

You will also see a report from 

ISMP examining the strengths and 

areas for improvement in long term 

care pharmacy practice. This report 

outlines a Medication Safety Self-Assessment 

(MSSA) designed specifically 

for multidisciplinary teams in long 

term care practice; a tool that you can 

take advantage of as a quality assurance 

measure. There are also considerations 

for the relief pharmacist 

and the pharmacy manager to ensure 

continuity of patient care and safety 

in the absence of regular staff. All of 

these messages are for discussion and 

consideration within each pharmacy 

practice to ensure quality assurance 

of the procedures that are in place 

for safe and effective patient care by 

pharmacists and the pharmacy team. 

Each issue of Pharmacy Connection 

features a Pharmacy Practice Q&A reflecting 

common inquiries directed to 

our pharmacy practice area. There are 

also regular alerts from Health Canada 

to inform pharmacists about recalls or 

changes which might affect your patients 

directly. 

These and other articles are provided 

to update you with new developments 

in the profession such as training 

requirements, regulation of pharmacy 

technicians, introduction of e-health 

initiatives, and to let you know about 

continuing education opportunities. 

Consider that reading Pharmacy Connection 

can be your quality assurance 

check on how to improve your practice, 

prevent common errors, and be prepared 

for future developments. We will 

be sending you an on-line questionnaire 

in mid-March to ask for your feedback 

on Pharmacy Connection. Let us know 

what information is valuable to you, 

and what other ways the College can 

provide you with quality improvement 

information that supports your practice. 

pharmacyconnection • March/April 2009 

5

elief pharmacist 

Profile of the Relief 

Pharmacist 

Nadia Sutcliffe BScPhm, R.Ph. 

Inspector 

Due to sheer number of staffing shortages 

in Ontario’s numerous pharmacies, 

more and more pharmacies are 

turning to agencies or independent 

contractors to supply temporary or relief pharmacists to 

cover vacations, illnesses, and requests for time off. There 

was a time when it was extremely difficult to find a licensed 

pharmacist for this purpose and many pharmacists went 

to work regardless of illness or did not take vacations. Depending 

on who you speak to, this situation still exists today. 

There are many pharmacists who do only relief work as a 

career choice. They enjoy the independence, flexibility of 

shifts, travel, and variety of practices. For pharmacies needing 

permanent staff, this leaves a smaller pool of pharmacists 

to hire from, which creates staffing shortages. 

Most relief pharmacists are very professional and take 

pride in their work. These practitioners are highly sought 

after and are often booked months or years in advance because 

of their stellar reputations. Nonetheless, some pharmacies 

have less than optimal experiences with relief personnel. 

There are stories of rudeness, lengthy personal conversations 

conducted on cell phones during shifts, arriving 

late -- or not at all, refusals to work in certain practices, and 

failing to counsel patients. These situations may be few and 

far between, but can be avoided altogether if proper steps 


are taken by all parties. Both the designated manager and 

relief pharmacist have specific responsibilities. They are 

encouraged to consult the Standards of Practice for Pharmacy 

Managers as well as the Standards of Practice to ensure 

maintenance of an ideal professional working environment. 

The designated manager is responsible for the operation 

of the pharmacy. The credentials and references of any 

pharmacist who will be working in the dispensary should 

be checked – including those of relief pharmacists. The 

Standards of Practice for Pharmacy Managers (s.5.1) states: 

The manager is responsible for ensuring that all staff in the 

pharmacy is competent to perform duties defined by their 

position, including specialized functions. Certification of 

staff may be required for some specialized functions. (Standard 

5.1) 

If the pharmacy engages in a practice which is not common 

to most retail pharmacies, such as a methadone maintenance 

program or specialty compounding, it is incumbent 

upon the manager to inform the relief pharmacist about this, 

and ensure that he or she is properly trained for, and comfortable 

dispensing in, these situations. It would be wise to 

have your pharmacy’s policies and procedures in writing, including 

what is expected from the staff in terms of professional 

duties; for example, mandatory patient counselling 

and documentation of dialogue. The manager should also 

determine the relief pharmacist’s experience on the store’s 

computer system and provide sufficient support staff to ensure 

that the dispensary runs smoothly. 

Pharmacists working relief have certain obligations. It is 

incumbent upon them to learn the specifics of where they 

will be working, such as location, hours of operation and 

any specialty practices in which the pharmacist would be 

expected to engage which require specific training, such as 

the provision of methadone for MMT. A name tag or lab 

coat should be worn to help identify them as pharmacists, 

especially if the patients will not know who they are. They 

have an obligation to the pharmacy and to the profession 

to uphold the standards of practice. This includes proper 

counselling about prescription and over-the-counter medications, 

documentation of dialogue, and practising in a manner 

which puts patient safety first. The relief pharmacist 

should communicate with the staff any preferences he/she 

may have in terms of work practices in the dispensary – it 

is better to be up front and avoid any miscommunication. 

There have been anecdotal reports of an “I’m only here for 

the day” attitude demonstrated during interactions with patients 

and staff and in general behaviour. This type of behaviour 

reflects poorly on the entire profession of pharmacy 

and can ruin the reputation of the pharmacy and, indeed, 

of the pharmacist. The relief pharmacist is an ambassador 

of sorts, and should do his or her best to project a positive 

image of the pharmacy. Being employed by the pharmacy, 

even for one day, mandates an obligation to uphold the standards 

of the pharmacy and the profession. 

If a problem occurs, the designated manager should make 

every effort to address it directly with the relief pharmacist 

and/or their agency to inform them of the situation. The 

relief pharmacist should have the opportunity to learn from 

the experience and receive feedback, positive or negative, 

as would any regular staff. 

Relief pharmacists provide a valuable and much-needed 

service in our profession. It is the duty of the designated 

manager to make available all the support that the relief person 

may require, and to ensure patient safety by checking 

the credentials of all staff in the pharmacy and setting policies 

and procedures which promote all the principles of our 

standards of practice. The relief pharmacist should act as an 

ambassador of the pharmacy profession, remembering that 

the main objective is to serve the patients and ensure optimal 

patient care. By keeping both the standards of practice 

for pharmacists and the standards of practice for pharmacy 

managers in mind, relief pharmacists have the opportunity 

to uphold the pharmacy’s professional image, and to ensure 

that patient safety and care levels remain constant, as they 

would with permanent pharmacy staff. 


7

eHealth Ontario 

The colleges of pharmacy, medicine and nursing are working with eHealth Ontario to enable two 

pilot projects in the province, one in Sault Ste. Marie and the other in Collingwood. 

Pharmacists are encouraged to subscribe to the eHealth Ontario electronic newsletter to keep 

informed on these pilots and other e-health initiatives which affect pharmacy practice. 

Visit http://www.ehealthontario.on.ca 

ePrescribing: A Way to Reduce Prescription 

Errors and Adverse Drug Events 

Group Health Centre in Sault Ste. Marie and Georgian 

Bay Family Health Team (GBFHT) in Collingwood 

will be participating in the Ministry of Health 

and Long-Term Care, eHealth Program’s ePrescribing 

demonstration project. ePrescribing is the electronic 

generation, authorization (signature) and 

transmission of prescriptions from doctors / prescribers 

to pharmacists / dispensers. Both locations 

are looking towards full deployment by April 2009. 

Dr. James Lane of the GBFHT says: “We are excited 

to be participating in the Early Adopters ePrescribing 

Project. It will insert local pharmacies and 

pharmacists into the circle of care and allow electronic 

communication of prescriptions between prescribers 

and pharmacists. The beneficiaries will be 

patients and families who will have access to better 

services sooner. 

With ePrescribing, drug prescriptions are no longer 

hand-written by physicians, decreasing the chance of 

problems associated with legibility and manual data 

entry. This lowers the potential for dispensing errors, 

which can easily result in adverse drug reactions, 

unnecessary hospitalization and even death. 

In addition, pharmacists won’t need to retype paper 

prescriptions, eliminating another potential source for 

human error. As an added benefit, electronic delivery 

of prescriptions to pharmacists means less wait time 

for patients, since prescriptions may be filled before 

the patient even gets to the pharmacy. 

Informing a Provincial Solution and 

Regulatory Standards 

Each site is implementing a different solution based 

on their existing technology. The results and lessons 

learned, particularly the impact of electronic prescribing 

on physicians, pharmacists and patients, will 

be assessed and used to inform Ontario’s provincial 

ePrescribing solution. 

In addition, regulatory colleges such as the College 

of Physicians and Surgeons of Ontario, the Ontario 

College of Pharmacists and the College of Nurses of 

Ontario, are being engaged to ensure participating 

physicians, pharmacists and nurse practitioners are 

able to meet their professional requirements. The 

findings will be shared to help determine whether any 

changes to professional practice regulations, standards 

and guidelines are needed. 

A provincial ePrescribing solution will dramatically 

reduce the 400,000 preventable reactions to medication 

estimated to occur each year in Ontario, 4,000 

of which result in death. 

Find out more about Group Health Centre at 

www.ghc.on.ca and Georgian Bay Family Health 

Team or visit their website at www.gbfht.ca. 


Ontario’s eHealth Strategy 

www.ehealthontario.on.ca. 

eHealth Ontario is a new agency that 

will play the leading role in harnessing 

technology to improve 

patient care and safety. 

We will deliver clear, measurable and transparent results 

for patients and will focus on excellence in customer service, 

which means ensuring that priority initiatives yield results for 

patients and that the services to support new electronic tools 

and information always meet customer needs. 

Driven and supported by the priorities of Government, the 

Strategy is focused on results for three clinical priorities: 

• Tools to control and manage diabetes more effectively to reduce 

associated complications and costs; 

• On-line management of prescription medications to minimize 

preventable adverse drug events; and 

• Reduced waits in Ontario emergency departments and the incidence 

of inpatients in acute care settings waiting for alternative levels of care. 

Pharmacists: Keep informed on the latest developments in Ontario’s ehealth strategy; 

subscribe to our newsletter by visiting: http://www.ehealthontario.on.ca 


9

coroner’s report 

Eighteenth Annual Report of the Geriatric 

and Long Term Care Review Committee to the 

Chief Coroner for the Province of Ontario 

SEPTEMBER 2008 

Tof cases referred by coroners. The committee conducts 

he Geriatric and Long Term Care 

Review Committee of the Chief 

coroner for the Province of Ontario 

has completed its review 

an independent review of the available records relevant to 

the specific case and prepares a final report which includes 

recommendations aimed towards the prevention of future 

deaths in similar circumstances. The recommendations 

are intended to promote discussion and initiate change. 

The following recommendations which may be relevant to 

pharmacy practice in geriatric and long term care are reprinted 

for your information; the complete report, including 

examples, can be found at http://www.mcscs.jus.gov.on.ca 

Medical / Nursing Management 

• Health care professionals caring for elderly residents 

of long term care homes should be reminded that pain 

is one of the most common, treatable symptoms in the 

elderly. Some of the principles of good geriatric pain 

management include the following: 

a) Identification of the cause of the pain, 

b) Regular, not PRN administration of pain medications, 

beginning with non-narcotic medications such 

as Acetaminophen, followed by narcotic medications 

when and if the non-narcotic medications are no 

longer effective, 

c) Regular, ongoing, careful assessment of the pain, including 

titration of the dosage depending on the patient’s 

response, 

d) Standardized assessment of the patient’s pain including 

both typical (complaints of pain), and atypical 

(agitation, loss of appetite), symptoms and signs, 

e) Utilization of physiotherapists or occupational therapists 

on alternative positioning in chair or bed to 

maximize comfort. 

• Health care professionals should be reminded that disease 

presentation in the elderly is frequently atypical 

and may vary greatly from patient to patient. A subtle 

change in a patient’s clinical status may well indicate that 

something serious is going on which may not be readily 

apparent. The underlying cause(s) of these atypical 

presentations may be missed if the investigator does not 

obtain an appropriate history, conduct a thorough examination, 

and judiciously utilize available laboratory and 

imaging resources. 

For example, the lack of fever is not uncommon in a severely 

septic elderly patient. 

• Health care professionals and all long term care homes 

in the Province of Ontario should be reminded of the 

importance of providing basic care needs to ill, elderly 

residents no matter where the long term care home is 

located in the Province. This includes evidence based 

assessment, pain management, and management of 

pressure ulcers. While some long term care homes located 

in remote northern communities may have limited 

resources to manage these needs, steps should be 

taken to ensure that the basic care needs of their residents 

are met. 


• Health care professionals and all long term care homes 

in the Province of Ontario should be reminded of the 

importance of developing and utilizing a comprehensive 

care plan to prevent and manage pressure ulcers. Not 

only should the care plan utilize evidence based practices, 

but also it should include policies and procedures 

to systematize these practices whenever possible. The 

importance of involving the entire health care team, including 

physicians in the prevention and management of 

pressure ulcers, cannot be overemphasized. 

Communication and Documentation 

• Health care professionals should be reminded of the importance 

of keeping complete, comprehensive, and accurate 

progress notes regarding treatment decisions and 

assessments. Frequently, the Committee finds these 

notes to be absent, scanty, incomplete, irrelevant, inaccurate, 

and/or illegible. These notes should meaningfully 

reflect issues identified by all members of the health 

care team (including the family) and include the reason 

why certain treatments are/are not being done in relation 

to these issues. 

Institutions need to develop quality assurance programs 

in order to determine their level of compliance with these 

programs and to correct any deficiencies where present. 

• Health care professionals should be reminded that family 

members are a vital member of the health care team. 

Family members’ concerns and observations should 

be acknowledged, taken seriously, and responded to 

in a timely fashion. The importance of documenting 

family interactions reflecting serious concerns cannot be 

overemphasized. 


of good communication amongst ALL members 

of the health care team including family members 

in situations where a patient’s clinical condition suddenly, 

unexpectedly, and unexplainably changes, and/ 

or when family members have expressed concerns regarding 

the patient’s clinical course. The importance 

of documenting the information communicated, and 

with whom the communication has occurred, cannot be 

overemphasized. 

• Health care professionals should be reminded of the 

importance of communicating with patients, if competent, 

and/or family members and/or substitute decision 

makers, the need for various treatment modalities 

and what alternatives exist to the recommended 

treatment modalities. Documentation of the information 

exchange on the medical record should be 

mandatory. 


of communication with families regarding severely 

behaviourally challenged demented elderly family 

members, especially about the potential risks and benefits 

of available treatment interventions including the use 

of psychotropic medications. 

• Health care professionals and all long term care homes in 

the Province of Ontario should be reminded of the importance 

of good communication with family members 

during an outbreak situation when visiting restrictions 

are imposed. A plan of action should be in place to maximize 

communication during the outbreak. 

Use of Drugs in the Elderly 

• Health care professionals should be reminded of the 

importance of ensuring that elderly patients who 

require opiates or other proconstipatory medications, 

are placed on a well defined bowel management 

protocol which includes careful monitoring to 

avoid the development of constipation and potential 

serious risk for the development of obstipation and 

obstruction. 

• Health care professionals should be reminded that constipation 

is an almost always universal complication of 

narcotic analgesics in the elderly. The development of 

constipation should be anticipated and steps taken to 

prevent and manage it every time a prescription is written 

for a narcotic analgesic. 


of ordering a serum albumin when assessing 

drug levels of highly protein bound medications such as 

Phenytoin Sodium. 


11

pharmacy accreditation renewals 2009 

There has been no increase in Pharmacy fees for 2009 

Your annual pharmacy accreditation renewal fee of $810.31 * is due no later than 

May 10, 2009. Renewal forms will be mailed to each pharmacy by mid-March 

While the pharmacist annual renewal has moved online, the pharmacy accreditation renewal process remains paper-based. 

Why? The information on the accreditation renewal form and any changes made to it must be acknowledged, currently - by 

way of signature - by all Directors and the Designated Manager of each pharmacy. 

FEE PAYMENTS 

Annual Pharmacy Fees due May 10, 2009 

Pharmacy fees of $810.31 ($771.72 + $38.59 GST) must be 

received and/or postmarked no later than May 10. 

Paying by Cheque 

Make sure your cheque is signed and made payable to 

the Ontario College of Pharmacists or OCP in the amount 

of $810.31 ($771.72 + $38.59 GST). Please write your 

Pharmacy Accreditation number and Invoice number on 

the front of your cheque. 

NSF cheques are treated as late and incur both a late 

penalty fee and a $20 NSF service charge. All unsigned 

cheques will be returned for signature. 

Paying by Credit Card 

We accept payment by VISA, MasterCard or American 

Express. Enter your credit card number and the expiry date 

of your credit card in the box under Payment Information 

on your renewal form. Please be sure to sign the credit 

card section giving us authorization to process the credit 

card payment in the amount of $810.31. 

RECORDS UPDATE 

Updates are required for 

the following: 

• Which pharmacists 

(with and without 

signing authority), and 

technicians are practising 

at the pharmacy 

• Lock and leave practices 

• Methadone dispensing 

• Pharmacy website information 

• Indication of which of the College-approved Drug 

Information Services the pharmacy subscribes to 

As outlined in the Standards for Designated Managers, 

acknowledgement of all directors and designated 

managers is a requirement of every pharmacy when 

reporting a designated manager change. You can update 

this information on the renewal form or download the 

Acknowledgment/Change of Designated Manager form by 

clicking on the “college forms” link at the bottom of our 

home page at www.ocpinfo.com 

Once processed, the certificates of accreditation and 

income 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 due date) 

or $157.50 (if paid more than 30 days after the due date). 

This includes cheques that are received early but postdated 

after May 10, 2009. Late payments are not processed until 

the late payment fee has been received. 

*All fees listed above include GST. 

For further information contact: 

Client Services at (416) 962-4861 Ext. 300 or by email at 



moving forward with technology 

With the successful launch of the Online Pharmacist Fee Renewal in January, we are 

monitoring member reaction to this new platform, as we continue to evaluate ways to 

improve College and Member processes through the use of technology. 

The online process has accelerated renewals significantly. We are pleased to report that 

as of February 19, 2009, 45% of pharmacists have completed Step 1 (the information 

renewal portion of their annual renewal), two thirds of which have also completed Step 

2 (payment). This compares very favourably to last year, when only 17% of pharmacists 

had completed their information renewal and payment as of the same date. 

Members share their first experience with 

the new online renewal process: 

“I called last week to complain about the new renewal process. I just completed it and 

it was really easy, so I wanted to apologize for complaining last week.” 

“Oh my goodness... I did it! I can’t wait to tell my grandson - he’ll be so proud of me.” 

“I’m uncomfortable with the new technology adopted by the college.... members should 

be given the choice to do their renewal online or by paper”. 

One member had Client Services walk him through the new online renewal process. 

Although he expressed his annoyance throughout the process, once he completed it, he 

said “This wasn’t so bad...now I’ll be able to help my wife complete her annual renewal !”. 

Stay tuned . . . 

We will continue to keep you informed about the success of this process as well 

as other initiatives the College is undertaking, to develop enhanced solutions 

through the use of technology. 


13

practice Q&A 

Greg Ujiye, R.Ph., B.Sc.Phm. 

Professional Practice Advisor 

QCan you clarify whether prescriptions and 

refills for all controlled substances expire or 

are no longer valid after one year, or only those for 

benzodiazepines and targeted substances? 

Pharmacists frequently ask for clarification on this issue. It 

is only prescriptions for benzodiazepines and targeted substances 

which expire or are no longer valid after one year 

from the date the prescription was written. In addition, refills 

are no longer valid if one year has elapsed from the time 

the prescription was written. It is important to emphasize 

that the year counts from the time the prescription was 

written by the prescriber and not from when the prescription 

was first dispensed. 

This requirement is found in s.52(c) of the Benzodiazepine 

and Targeted Substances Regulation. The Food and 

Drugs Regulation, Part G - Controlled Drugs places no such 

restriction or requirement on controlled drugs. 

QWhat is the difference between a controlled drug 

and a controlled substance? 

These terms are defined and discussed in two different 

Acts. 

A “controlled drug” is defined in the Food and Drugs Regulation, 

Part G – Controlled Drugs and is any drug (or preparation) 

listed in Parts I, II, and III of the Schedule to Part G. 

A “controlled substance” is defined in the Controlled 

Drugs and Substances Act (CDSA) and refers to any substance 

listed in Schedule I, II, III, IV, and V of the CDSA. 

These Schedules include controlled drugs, narcotics, benzodiazepines 

and targeted substances. 

The term “controlled substance” refers to all drugs and 

substances covered by the CDSA and encompass all activities 

related to the control of those drugs and substances. 

The definitions for “narcotic,” “benzodiazepine and targeted 

substance” are found in their specific regulation to 

the CDSA. 

QWe occasionally receive a notice that a physician 

is restricted from prescribing controlled drugs 

and narcotics. Does this include benzodiazepines and 

targeted substances? 

No. “Controlled drug” and “narcotic” are defined terms. 

In such cases the physician is restricted from prescribing 

controlled drugs listed in Parts I, II, and III of the Food and 

Drug Regulation, Part G-Controlled Drugs or narcotics found 

in the Schedule to the Narcotic Control Regulations. The 

physician is free to prescribe benzodiazepine and targeted 

substances. If the notice states the physician is restricted 

from prescribing controlled substances then the physician is 

not allowed to prescribe controlled drugs, narcotics, benzodiazepines 

or targeted substances. 

QWhere can I get a new narcotic register to record 

my controlled drug and narcotic purchases? 

Pharmacists can download new pages in either a PDF or 

Word document from the OCP website. Click on the menu 

bar item “College Forms” at the bottom of the webpage. 

Choose either the PDF or Word document of “Pharmacy 

Narcotic and Controlled Drug Register” on the screen that’s 

displayed. 


QTo fill or not to fill? 

To fill or not to fill? That is the question! What is the status of prescription refills when the prescribing physician is deceased 

or has moved away, or when the physician’s license has been suspended or revoked? The Practice Advisory staff continues 

to receive numerous inquiries regarding the status of prescription refills once the status of a physician’s license changes. The 

chart below provides some guidelines for action which may reduce confusion in the future. 

Physician Deceased 

Physician Moved 

Physician Retired 

Physician’s License 

Physician’s Licensed 

(out of Canada) 

Suspended 

Revoked 

• License not 

• License maintained 

maintained 

Refills are invalid 


Refills valid for 1 year 



Use professional 


Any script written 

Any script written 

judgment** 

judgment 

prior to the date of 

prior to the date of 

suspension would be 

revocation would be 

valid. 

valid. 

Refer patient to new 


physician or walk-in 




clinic 

clinic 

judgment 

judgment 





clinic 

clinic 

• License not 

maintained 



judgment 



clinic 

** As summarized above, if the physician is deceased or if his or her license has been suspended or revoked; a pharmacist may 

use professional judgment to determine when it is appropriate to provide a refill or direct the patient to consult another prescriber. 

Professional judgment may be used where all reasonable options to obtain proper authorization have been exhausted. In order to 

ensure the continuity of patient care, and provided the patient’s condition appears stable. As always, pharmacists are accountable 

for their actions, and should document accordingly as per the Documentation Guidelines. 


15

online survey 

Here’s your chance to 

Speak up about 

Pharmacy Connection! 

The Editor asks… 

“What do you REALLY THINK about your profession’s journal?“ 

We invite you to take a moment to complete a brief online survey to help the College 

understand your thoughts, opinions, and reading habits of Pharmacy Connection – and your 

“wish list” too, as we look for ways to bring our members more practice-relevant information 

through this publication. 

Sample questions : 

• What articles do you find most interesting and valuable? 

• What topics would you like to read more about? 

• What improvements would you like to see in Pharmacy Connection? 

• Do you prefer to receive this publication in a print or electronic version? 

An invitation with a link to the survey will be emailed to you mid-March. 

Thank you – 

Your thoughts and suggestions will inform future editorial content, design and distribution. 

Survey highlights will be published in a future issue of Pharmacy Connection. 


health canada advisories & notices 

Feb 18, 2009 

Feb 17, 2009 

Feb. 17, 2009 

Jan 30, 2009 

Jan 13, 2009 

Jan 12, 2009 

Jan 7, 2009 

Jan 6, 2009 

Jan 5, 2009 

Biogen Idec Canada Inc., has updated the Tysabri product monograph with new information on Progressive 

Multifocal Leukoencephalopathy (PML). There have been 5 cases of PML reported in patients receiving 

Tysabri (natalizumab) as monotherapy. 

Health Canada is informing expectant mothers and women who are planning pregnancy taking the product 

PregVit Folic 5 and PregVit distributed by Duchesnay Inc. to check the product’s individual sealed packages. 

Reports related to incorrect packaging of some blister packs have been received by Health Canada; however 

no concerns have been raised regarding the tablets themselves. 

Health Canada is advising Canadian consumers and retailers to exercise caution when purchasing 

toothbrushes. Counterfeit toothbrushes falsely labeled as Colgate Massager, Colgate Navigator, Oral B 

Classic 40, Oral B Contura and Colgate 360 have been found on the Canadian market. 

Health Canada is advising consumers not to use 4 foreign products: Zhuang Tjar Gere, Zhixhue Capsules, 

Tonik Warisan Banjar and Healthily Slim. The unauthorized product Zhuang Tjar Gere, because it contains 

the undeclared prescription drugs sildenafil and tadalafil, and may cause serious cardiovascular side-effects. 

The unauthorized product Zhixhue Capsules manufactured by Vital Pharmaceutical Holdings Ltd., due to 

concerns of serious side- effects, including liver dysfunction. The unauthorized product Tonik Warisan 

Banjar, because it contains undeclared dexamethasone and may cause serious side-effects. The unauthorized 

product Healthily Slim, because it contains the undeclared prescription drug sibutramine, which should only 

be used under the supervision of a health care professional. 

This is an update of important safety information on Botox and Botox Cosmetic (botulinum toxin type A) and 

the potential risk of serious adverse effects of muscle weakness remote to the site of injection, also referred 

to as possible distant spread of toxin. 

Novopharm Ltd., in consultation with Health Canada is recalling 3 lots of Dobutamine Hydrochloride 

Injection 250 mg/20ml, due to an error in the dosing range shown on the vial labels. 

Canadian healthcare professionals and institutions are being provided with revised dosage conversion 

guidelines for switching patients from shorter acting opioid narcotics to fentanyl transdermal systems. 

Canadians are advised that healthcare professionals and institutions have been sent the new guidelines 

Health Canada is reminding Canadians who are taking, or considering taking, the smoking-cessation aid 

Champix of important safety information for this product. Health Canada is also informing Canadians that 

it is in the process of further strengthening the labelling for the drug with respect to the risk of serious 

psychiatric adverse effects. 

PPC (Pharmaceutical Partners of Canada Inc.), in consultation with Health Canada is recalling Lot 7101490 of 

Piperacillin/Tazobactam for Injection, 4.5 g/vial (DIN 02305615) due to the finding of the presence of foreign 

particulate matter in some vials from this lot. 

For complete information & electronic mailing of the Health Canada Advisories/Warnings/Notices subscribe online at: 

http://www.hc-sc.gc.ca/dhp-mps/medeff/index_e.html 

MedEffect e-Notice is the new name which replaces Health Canada’s Health_Prod_Info mailing list. 

The content of the e-notices you receive will remain the same and are now part of MedEffect, a new Health Canada Web site dedicated to 

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

Health Canada Notices are also linked under “Notices” on the OCP website: www.ocpinfo.com 


17


continued on page 21 


19

pharmacy technician Q&A 

Susan James 

Project Director, Pharmacy Technician Regulation 

QI am confused about the Bridging Education 

Program. I thought everyone had to complete 

it, but now I understand that some people will be 

exempted from it. How do I know if I qualify for an 

exemption, and how do I apply for one? 

The Bridging Education Program is proposed as a registration 

requirement for anyone who wants to become registered 

as a pharmacy technician and did not graduate from 

an education program accredited by the Canadian Council 

for Accreditation of Pharmacy Programs (CCAPP). Please 

note that CCAPP began to accredit pharmacy technician 

programs in 2008; therefore, graduates from any program 

prior to 2008 are required to complete the Bridging Program. 

A list of accredited schools and the dates of effectiveness 

are available on the OCP website under the Pharmacy 

Technician section. (www.ocpinfo.com>pharmacy 

technicians>CCAPP Accreditation) 

The Bridging Education Program consists of four continuing 

education courses: Professional Practice, Pharmacology, 

Product Preparation and Drug Distribution, and a structured 

practical evaluation following the Drug Distribution 

course. Although each course must be completed by those 

required to do the Bridging Education Program, there will 

be a mechanism, called Prior Learning Assessment, available 

to allow individuals to demonstrate they already have 

the knowledge and skills that will be taught and evaluated in 

three of the four courses. Neither the Professional Practice 

course nor the structured practical evaluation (following the 

Drug Distribution course) will be eligible for Prior Learning 

Assessment, which means that both will have to be completed 

by everyone. 

Once Prior Learning Assessment is available (it is anticipated 

by spring 2009), individuals will be able to review 

course materials to determine if they already possess 

the knowledge and skills needed to meet the course outcomes. 

Individuals who believe they have the necessary 

competencies will be required to register for each course, 

but may request a Prior Learning Assessment. The assessment 

will involve demonstration of the applicant’s knowledge 

and skills through an examination. Individuals who 

are successful will be considered to have met the course 

requirements. There is a course fee for Prior Learning Assessment, 

although it is typically less than a full course fee. 

Individuals who are unsuccessful with the assessment will 

be required to register and pay for the course again and successfully 

complete it. 

More details will be available as the process develops 

further. Be sure to sign up for e-mail notifications to stay 

informed. (www.ocpinfo.com > pharmacy technicians > 

Stay Informed) 

QThere are no Bridging Education Programs close 

to where I live. How am I supposed to complete 

the program when I already have a full-time job and a 

family to manage? 

The Bridging Education Program is still under development. 

The initial delivery of each course has been at a community 

college with a CCAPP-accredited pharmacy technician program; 

unfortunately, these are limited in number and not welldistributed 

across the province. As the program develops, 

there are two strategies that will be used to make it more 

accessible: satellite or affiliated delivery and on-line courses. 

The accredited programs will remain responsible for administration 

of the program, but will establish partnerships 

in communities throughout the province to offer classroom 

delivery of the courses. Courses may be held at your local 

community college facility or any other setting that is suited 

for the course. For example, in some communities, satellite 

delivery has been established using classrooms at the 

local hospital. In all cases, registration for the course occurs 

through the accredited community college. A listing of the 

satellite and affiliated delivery sites is provided on the OCP 


website under the Bridging Program heading in the Pharmacy 

Technician section. 

Each of the courses will also be available on-line; it is anticipated 

by mid-2009. While most of the courses will be 

delivered completely on-line, at least one course (Product 

Preparation) will involve an on-site practical lab component. 

The accredited community colleges will be responsible, 

once again, for delivery of on-line courses and, as described 

above, will arrange for the practical lab component to be delivered 

in communities throughout the province. More details 

about on-line courses will be provided as they become 

available. Completion of the structured practical evaluation 

which follows the Drug Distribution course is being designed 

to take place at your worksite. 

continued from page 19 


21

close up on complaints 

Do Medication Errors Result in a 

Referral to the Discipline Committee? 

TCommittee of the College and the factors that contribute to 

A MESSAGE FROM THE CHAIR OF THE DISCIPLINE COMMITTEE 

his is the first of a series of articles 

aimed at increasing pharmacists’ 

understanding of the types of matters 

that are referred to the Discipline 

the decision to refer a matter to discipline. 

In particular, this article discusses medication errors that 

are reported to the College as formal complaints. 

When a medication error is reported to the College as 

a formal complaint, the College investigates the matter by 

obtaining relevant documents from the pharmacy. The College 

may also obtain statements from the parties named in 

the complaint. The College provides the pharmacist who is 

the subject of the complaint (“the Member”) with the opportunity 

to respond to the complaint by recounting their 

recollection of the event that resulted in the complaint. 

The results of the investigation, including the Member’s 

response, are placed before the Complaints Committee, one 

of two screening committees of the College. As a screening 

committee, the role of the Complaints Committee is to review 

the complaint, consider the submissions of the Member, 

consider or make all reasonable efforts to consider all 

records and documents it believes are relevant to the complaint 

and subsequently arrive at a disposition. The Complaints 

Committee in its deliberations recognizes that the 

cause of medication errors are often multi-factorial involving, 

but not limited to, prescription processing and dispensing 

procedures in place at the pharmacy, counselling issues, 

staff training and supervision. 

The Complaints Committee may arrive at a number of 

dispositions. It may issue a written caution to the Member, 

require the Member to appear before it to be cautioned, suggest 

remediation that may assist the Member to overcome 

Sherif Guorgui 

any deficits in his or her practice or take any other action 

that is within its jurisdiction. The Complaints Committee 

may also refer a specified allegation of the Member’s professional 

misconduct or incompetence to the Discipline Committee 

if the allegation is related to the complaint. 

Currently, the majority of complaints about medication 

errors are NOT referred to the Discipline Committee. As a 

matter of fact, in 2002, 17 of the 18 (94%) complaints about 

medication errors were referred to the Discipline Committee 

whereas between 2003 – 2008, only 7 out of a total 

of 42 (16%) complaints about medication errors were referred 

to the Discipline Committee. This change reflects a 

heightened desire on the part of the Complaints Committee 

to deal with complaints against Members about medication 

errors through remedial rather than punitive measures 

when it is satisfied the Member managed the incident 

in an ethical and appropriate manner that was in the best 

interest of the patient. 

Of particular interest to the Complaints Committee 

when it is reviewing a complaint about a medication error is 

whether the Member, after becoming aware that a medication 

error occurred, demonstrated insight into how the 

medication error occurred and took steps to prevent it from 

reoccurring. Also of interest to the Committee is whether 

the Member recognized his or her role in the medication 

error, whether the Member understood the medication involved 

in the error was a “red flag” drug that presented a 

greater risk for the commission of a medication error and, 

most importantly, what measures the Member took to act 

in the best interest of the patient to ensure that the patient 

did not continue to receive the wrong medication therapy. 

For example, when a Member deals with a medication 

error in a very transparent and expedient manner by taking 


measures such as calling the patient and disclosing what 

happened, apologizing for the error, notifying the prescriber 

and offering to remedy the situation to the extent possible, 

the Committee is more likely to view the actions taken by 

the Member to be driven by a desire to act in the patient’s 

best interest. 

Conversely, when the Complaints Committee is confronted 

with information that suggests that the Member did 

not take reasonable and necessary steps to act in the best 

interest of the patient and may have actually taken steps 

or measures to “cover up” the medication error in order to 

protect his or her reputation or to avoid having a complaint 

made to the College, the Committee is likely to view the 

Member’s conduct as placing his or her needs ahead of the 

patient’s needs and a breach of trust in the therapeutic relationship. 

Matters containing this type of information are 

generally viewed by a panel of the Complaints Committee as 

being very serious and worthy of a referral to the Discipline 

Committee. These referrals are generally accompanied by 

allegations of professional misconduct against the Member 

characterized as being dishonest, dishonourable or unprofessional 

and are commensurate with penalties that can be ordered 

by a panel of the Discipline Committee. Discipline proceedings 

are intended to serve as a specific deterrent to the 

Member and a general deterrent to the membership at large 

whereas dispositions made by the Complaints Committee 

are opportunities for the Member to be educated about or 

reminded of his or her professional obligations. 

The Complaints Committee may also refer a matter to the 

Discipline Committee when it is of the opinion that a Member’s 

practice may place the public at risk or when the Member 

has been the subject of multiple complaints of a similar nature. 

In summary, a medication error on its own does not result 

in a referral to the Discipline Committee. Rather it is the 

failure on the part of the Member, after he or she learns of 

the medication error, to demonstrate that he or she acted 

in a professional, accountable and ethical manner with an 

understanding that the needs of the patient are primary in a 

pharmacist – patient relationship that may result in a referral 

to the Discipline Committee. 

bulletin board 

The College bid a fond farewell to Cheryl Fernandes- 

Stechishin, Administrative Assistant in the Investigations 

and Resolutions department. Cheryl had been with the College 

since 2006 and has accepted a position in the Hearings 

Office with the Ontario College of Teachers. 

Lucy Wang, who has been providing services on a temporary 

basis, has recently joined the College in a permanent 

staff position in the Accounting department. Lucy had previously 

covered a maternity leave at the College and brings 

many years of accounting experience. 

Rahila Ovais recently joined the College as the part time 

Administrative Assistant in the Continuing Competency 

program. Rahila has extensive experience working in community 

pharmacies as a pharmacy assistant. 

Katryna Spadafore recently joined the College as the Administrative 

Assistant in the Investigations and Resolutions 

department. Katryna graduated with her Bachelors degree 

in Health Sciences and comes to us from the Alberta College 

of Occupational Therapists where she held the position 

of Registration Coordinator. 


23

structured practical training Q&A 

Diana Spizzirri, R.Ph., B.Sc.Phm., M.Ed. 

Penny Tsang, R.Ph., B.Sc.Phm. 

Deanna S. Yee, R.Ph., B.Sc.Phm., M.Sc. 

Registration Advisors 

QI am a Canadian pharmacy graduate about to 

begin an Ontario hospital pharmacy residency. 

Will this residency count toward the College’s 

internship requirement? If so, do I need to register as 

an intern with the College? 

Revision of Q&A that appeared previously in March/April 

2006 issue of this publication 

The College strongly encourages Ontario hospital residents 

to register as pharmacy interns during their residency 

program. Registration as an intern is required for 

residents who wish to practise in a community pharmacy 

or in an accredited, out-patient hospital pharmacy. Registration 

as an intern allows a resident to perform the controlled 

acts of a pharmacist, as well as to use the protected 

title of “intern.” 

Hospital residencies in Ontario are one-year, post-graduate, 

clinical practice programs during which pharmacy 

graduates must successfully complete a variety of clinical 

and administrative rotations. Through these rotations, 

residents may demonstrate entry-to-practice competencies 

established by the National Association of Pharmacy 

Regulatory Authorities (NAPRA) which form the basis of 

the SPT internship. Therefore, the College recognizes successful 

completion of hospital residency rotations in Ontario 

as meeting the minimum 12 week SPT internship requirement 

provided these competencies are met. 

To receive credit for SPT internship, the resident must 

• submit an internship application form and the internship 

application fee before beginning the residency training 

period that is to be counted toward the minimum 12 

week SPT internship. The Residency Coordinator or 

the Pharmacy Manager/Director is generally listed as the 

preceptor on the application form. 

• successfully complete rotations in drug distribution, 

pharmacy administration, drug information, and clinical 

practice, including the patient care activities assigned as 

part of the residency program in lieu of the SPT Internship 

activities. 

• complete the final SPT Internship self-assessment at the 

end of the rotation. 

The preceptor must also complete a final SPT Internship 

assessment and the Declaration of Completion, confirming 

that the resident has demonstrated his/her competency and 

is ready to be registered as a pharmacist. 

QI am an international pharmacy graduate. I 

completed Structured Practical Training (SPT) 

studentship, and then started my internship over one 

year ago. After completing only eight of the 16 weeks 

of internship training, I had to go back to my home 

country for personal reasons. I have now returned 

to Ontario to complete my internship and to become 

licensed as a pharmacist. Can I resume where I left 

off and complete the remaining eight weeks? 

The amount of training you require to become registered as 

a pharmacist in Ontario will depend on several factors. Since 

you must be registered as a pharmacist within three years 

of beginning your SPT, staff will first check the start date 

of your training to see if your registration status is still valid. 

SPT staff will then review the assessments you and your 

preceptor completed and submitted during your first eight 

weeks of internship to determine if you have been given 

credit for the training you completed (i.e., two four-weeklong 

assessment periods). If it appears that you were at 

the expected level of competency, you may be required to 

complete a minimum of eight more weeks of SPT internship. 

The remaining training time could in actuality be longer, 

because successful completion of SPT is based on demonstration 

of your competency, not just length of training. 

Since there was a significant gap in your training, you may 

need more time than the minimum to re-familiarize yourself 

with pharmacy practice in Ontario and to demonstrate 

your entry-to-practice competency. 

OCP staff will also check the validity of your language 

proficiency test scores. Since test scores are only valid for 

two years, you may need to submit current, acceptable fluency 

test scores or other non-objective evidence of your 

continued fluency to a Panel of the Registration Committee. 

Panels would require evidence that you have maintained 

your English or French proficiency. 

There are factors to consider before making a decision 

about your remaining training time. If there are any concerns 

about your continued competency, your application 

may be referred to a Panel of the Registration Committee 

for a decision on your remaining training requirements. 


deciding on discipline 

Case 1 

Dispensing without authorization; 

record keeping discrepancies 

Member: Helen Huh 

Pharmacy: MediSystem Inc., Toronto 

Hearing Date: December 4, 2008 

Facts 

This case proceeded by way of Agreed 

Statement of Facts and Joint Submission 

on Penalty. 

Ms. Huh was the Designated 

Manager of MediSystem (“the Pharmacy”), 

which currently provides 

pharmacy services to approximately 

165 long-term care homes which have 

approximately 17,318 beds. At all material 

times, the Pharmacy was partly 

owned and directed by Gary Chin. Mr. 

Chin was the Designated Manager of 

the Pharmacy from July 1999 to February 

2001. 

This case concerned prescription 

services provided to five residents of 

College Gardens, a non-registered 

long-term residential care facility providing 

residential facilities to a small 

number of individuals of varying ages 

with mental illness. College Gardens 

was owned by the same individual 

who owned Fairview Nursing Home, 

a registered long-term care facility. 

MediSystem entered into an agreement 

with Fairview Nursing Home to 

provide pharmacy services to its residents, 

as well as to those of College 

Gardens. 

The College received a complaint 

from an Ontario physician regarding 

her patient D.B., a 76-year-old woman 

diagnosed with schizophrenia. D.B. 

was a resident of College Gardens 

who had recently become a patient of 

the physician. The physician was concerned 

that the Pharmacy had been 

dispensing prescription drugs, including 

Isotamine, for D.B. for approximately 

seven years without any apparent 

prescription authorization or ongoing 

monitoring of the patient or her use of 

these drugs. 

In the course of investigating the 

complaint, it appeared to the College 

that there were other dispensing 

irregularities in relation to other residents 

of College Gardens. A further 

investigation was therefore carried out. 

That investigation revealed dispensing 

irregularities concerning four additional 

College Gardens residents. 

If she were to testify, Ms. Huh 

would explain that she understood that 

the Pharmacy would dispense medication 

to residents of College Gardens 

in accordance with the terms of the 

arrangement between the Pharmacy 

and both Fairview Nursing Home and 

College Gardens. Ms. Huh would testify 

that she understood that residents 

of College Gardens would be cared for 

by Fairview Nursing Home’s medical 

director and nursing staff, and that 

any authorized prescriptions for residents 

of College Gardens would be 

communicated to the Pharmacy by the 

prescribing doctor, or a nurse acting as 

agent for that doctor, by telephone or 

facsimile. 


would explain that as a result of the 

terms of the Pharmacy’s arrangement 

with Fairview Nursing Home and College 

Gardens, Mr. Chin’s assurances, 

and the random reviews she conducted 

of the Pharmacy’s records to ensure 

the Pharmacy obtained copies of any 

necessary documents related to the 

residents of College Gardens, Ms. Huh 

believed at all times that she and the 

Pharmacy were authorized to dispense 

the medications at issue. 


would state that any inaccuracies in 

the Pharmacy’s records relating to patients 

of College Gardens were the 

result of human error or technological 

error, both of which were beyond 

Ms. Huh’s control. She would further 

state that the prescriptions which are 

the subject of these allegations account 

for only 0.0002% of the prescriptions 

filled by the Pharmacy during 

this timeframe. 


would describe changes that have 

been made at the Pharmacy as a result 

of these proceedings to reduce the 

possibility that any future discrepancies 

might arise. These changes include 

reconfirming authorizations received 

from any rest, retirement or 

group home; ensuring quarterly medication 

reviews are conducted for all 

residents; and flagging three-month 

review dates in the Pharmacy’s computer 

system. 

Admission of Professional 

Misconduct 

The Member pleaded guilty to various 

acts of professional misconduct 

which occurred while she was acting as 

the Designated Manager of the Pharmacy, 

including dispensing drugs without 

prescriptions or other authorizations 

to various patients between May 

2004 to September 2004; dispensing 

Isotamine to D.B.; and discrepancies in 

record keeping relating to five different 

patients during the period May 2004 to 


25

deciding on discipline 

September 2004. The Member admitted 

that her conduct would reasonably 

be regarded by members of the profession 

as disgraceful, dishonourable 

and/or unprofessional. The Panel accepted 

the Member’s plea to these allegations 

and accepted the parties’ joint 

submission to withdraw the remaining 

allegations. 

Decision and Reasons 

The Panel was presented with an 

Agreed Statement of Facts for Sanction, 

and a Joint Submission on Penalty, 

as well as four precedent cases. 

There was no case presented which 

was directly on point. 

The Panel was particularly troubled 

by the Member’s apparent failure to 

understand and/or take seriously her 

obligations as Designated Manager of 

the pharmacy in question. The Panel 

was comforted by the fact that the 

Member has accepted responsibility 

for her actions, and co-operated fully 

in the College’s investigation. However, 

the Panel was loath for this case 

to be perceived as being primarily one 

of record keeping. The case goes much 

deeper than that, and had potential for 

real impact on patient care. 

The Panel was mindful of the obligations 

of the Member to the public 

in protecting public safety. The Panel 

found offensive the statistic presented 

that the underlying problematic prescriptions 

constituted only 0.0002% 

of the total prescriptions of the Pharmacy 

during the timeframe of the investigation. 

The Member had an obligation 

to ensure that not a single patient 

was exposed to potential harm, 

particularly in her role as Designated 

Manager. 

Order 

1. A reprimand. 

2. Specified terms, conditions, or limitations 

on Ms. Huh’s Certificate 

of Registration requiring her to 

complete successfully, at her own 

expense, within twelve months of 

the date of this Order, remedial 

training as follows: 

a. CPS I Module 1: Pharmaceutical 

Care – Applied Therapeutics 

Lecture Series, 

b. CPS I Module 3: Basic Professional 

Practice Labs; both from 

the Canadian Pharmacy Skills 

Program offered through the 

Leslie Dan Faculty of Pharmacy 

at the University of Toronto, and 

c. the Jurisprudence seminar offered 

by the College. 

3. A suspension of Ms. Huh’s Certificate 

of Registration for a period of 

three months, with two months of 

the suspension to be remitted on 

condition that the Member complete 

the remedial training exercises 

specified in paragraph 2 above; 

4. Costs to the College in the amount 

of $7,500.00. 

Reprimand 

The Panel was concerned and disappointed 

that for a pharmacist who 

has over 20 years of experience, and 

who has accepted the role and responsibilities 

of the Designated Manager, 

there would be such ongoing failure in 

record keeping practices, which could 

have resulted in serious harm to the patients 

impacted. 

The Panel was also troubled by Ms. 

Huh’s explanation that the prescriptions 

which were the subject of this 

hearing accounted for only 0.0002% 

of the prescriptions filled by the Pharmacy 

during the timeframe of the investigation. 

The Panel hoped that the 

Member understands that this statistic 

is of no value when it comes to abiding 

by the standards of practice and, 

most importantly, to ensuring patients’ 

safety. The attempt to use these statistics 

to possibly minimize the magnitude 

and seriousness of the matter was 

very disturbing. 

With that being said, the Panel 

would like to acknowledge that the 

Member did cooperate with the College 

throughout the investigation, and 

the Panel was also pleased to hear that 

the Member has already made changes 

to her practice to reduce the possibilities 

of such discrepancies in the future. 

The Panel trusted that Ms. Huh 

learned a valuable lesson throughout 

this process and that the remedial 

courses she will undertake will help 

her realize that this case was not about 

poor record keeping but about ensuring 

patients’ safety. 

Case 2 

Dispensing error 

Member: George Politis 

Pharmacy: Peoples Drug Mart, Toronto 

Hearing Date: December 18, 2008 

Facts 

This case proceeded by way of Agreed 

Statement of Facts and Joint Submission 

on Penalty. It concerned a dispensing 

error in which the pharmacy 

dispensed Apo-Prednisone 50mg to a 

patient instead of the Prandase 50mg 


which had been prescribed on a Limited 

Use form. The pharmacy had dispensed 

Prandase to the patient on a 

regular basis for several years, but had 

not previously dispensed prednisone to 

the patient. The threat of patient harm 

in this case was significant, as the patient 

was an elderly person with diabetes, 

and prednisone could cause his 

blood glucose to increase. 

Admission of Professional 

Misconduct 

The Member admitted that he checked 

the label against the medication inside 

the vial and dispensed the medication. 

He also counseled the patient’s spouse. 

However, he did not check or compare 

the original Limited Use Prescription 

with either the tablets in the vial or the 

label on the vial. 

The Member acknowledged that 

he dispensed prednisone 50mg instead 

of the Prandase 50mg that had been 

prescribed. He acknowledged that he 

failed to properly check the prescription 

before the drug was dispensed. He 

also acknowledged that he should have 

made further inquiries about the medication 

in light of the patient’s diabetes 

and the possible effect of prednisone on 

that condition. The error was reflected 

in the records of the pharmacy. 

The Member pleaded guilty to allegations 

that he failed to maintain the 

standards of practice of the profession, 

and that he breached sections 155 and 

156 of the Drug and Pharmacies Regulation 

Act. 

Decision and Reasons 

The Panel acknowledged that there 

were a number of mitigating factors 

in this matter, including that the 

Member cooperated with the College; 

the Member accepted responsibility by 

entering a guilty plea; the Member has 

taken steps to correct practice deficiencies 

within the pharmacy to avoid 

these types of problems; and the Member 

has already taken the remediation 

courses agreed to in the Joint Submission 

on Penalty. 

Nevertheless, there are aggravating 

factors in this case as well. The patient 

had been a patient of the pharmacy for 

some 25 years and had prior prescriptions 

for Prandase dating to 2002, but 

had never been prescribed prednisone. 

The nature of the medication and daily 

dose dispensed (a new medication to 

this patient) should have raised questions 

in the mind of the pharmacist and 

resulted in additional caution, particularly 

given the patient’s medical history. 

The pharmacist is ultimately responsible 

to ensure that the proper medication 

is dispensed. Had the very basic 

step of checking the dispensed medication 

against the original prescription 

documentation occurred, this error 

would likely have been prevented. 

Given that the Member had been cautioned 

by the Complaints Committee 

about a separate dispensing error two 

months prior to the error at issue in this 

case, the Member should have been 

far more cautious in his dispensing of 

drugs. 

Order: 

5. A reprimand. 

6.Specified terms, conditions, or limitations 

on Mr. Politis’s Certificate 

of Registration requiring him to 

complete successfully, at his own 

expense, within six months of the 

date of the Order, remedial training 

as follows: 

(a) “Confronting Medication Incidents” 

offered through the Ontario 

Pharmacists’ Association, 

and 

(b) “Root Cause Analysis” offered 

through the Institute for Safe 

Medication Practices. 

7. A suspension of Mr. Politis’s Certificate 

of Registration for a period 

of two months, with one month of 

the suspension to be remitted on 

condition that the Member complete 

the remedial training exercises 

specified in paragraph 2 above. 

8. Costs to the College in the amount 

of $3,000.00. 

Reprimand 

The nature of the Member’s professional 

misconduct was cause for great 

concern, as it related to public safety. 

The Member failed to conduct the 

most basic of pharmaceutical functions, 

namely the physical checking of 

the prepared prescription against the 

original document. The public relies on 

the pharmacist to carry out this basic 

function to protect them. 

The Panel found the circumstances 

around the error to be disconcerting, 

as the Member knew the patient and 

his medication history and should have 

acted in his best interest. 

In light of the previous two medication 

errors, the Panel was hopeful the 

Member had learned from this experience 

and would not find himself before 

a Panel of the Discipline Committee 

again. The Panel trusted that the 

Member would use this experience to 

become a more conscientious pharmacist 

through the course work he had already 

undertaken. 


27

focus on error prevention 

Ian Stewart, R.Ph., B.Sc.Phm 

Toronto Community Pharmacist 

Ambiguous Prescriptions 

prescription, the pharmacist identified the computer entry 

error and corrected the instructions to read “one drop into 

the right eye twice daily”. 

Key contributing factor: 

Misinterpretation of the abbreviation “OD”. 

Pharmacists often receive prescriptions that may be 

misinterpreted due to their ambiguity. The following 

three cases have been reported. 

Case 3 

Case 1 

The above prescription was presented to a pharmacy 

technician at a community pharmacy. The prescription 

was interpreted and entered as Topicort® Cream (regular 

strength) to be applied twice daily. Thirty grams were then 

weighed, labelled and given to the pharmacist for checking. 

On checking the prescription, the pharmacist observed 

that the strength of the cream prepared was actually 0.25% 

desoximetasone instead of the 0.05% prescribed, which is 

the strength of Topicort® Mild Cream. 


The word “Mild” was omitted when writing the name of 

the drug. 

Case 2 

The instructions for using the above ophthalmic drops 

were entered into the computer as “one drop into the affected 

eye once or twice daily”. However, on checking the 

The above prescription was initially entered into the computer 

as Valproic Acid. However, the pharmacist later contacted 

the prescriber who confirmed that he intended to 

prescribe divalproex sodium. 


The names of two different drugs that are not interchangeable 

were written on this prescription. 

Recommendations: 

• Always contact the prescriber to confirm/clarify prescriptions 

that may be misinterpreted due to ambiguity. 

• Use the patient’s medication history as a tool to clarify or 

confirm ambiguous prescriptions. 

• Consider the usual dosage and dosing interval of the drug 

being dispensed. 

• Educate all pharmacy staff about problematic abbreviations 

that may be misinterpreted. An extensive list may be 

accessed at http://www.ismp.org/PDF/ErrorProne.pdf . 

• Ensure that all staff are aware of problematic drug pairs 

often involved in medication errors. 

Please continue to send reports of medication errors in confidence 

to Ian Stewart at: ian.stewart2@rogers.com . 


CE resources 

Visit the College’s website: www.ocpinfo.com for a complete listing of upcoming events and/or 

available resources. A number of the programs listed below are also suitable for pharmacy technicians. 

GTA 

March 27-29, 2009 

Diabetes Certificate Program 

Ontario Pharmacists’ Association 

Toronto, ON 

Contact: Penny Young 

Email: pyoung@dirc.ca 

Tel: 416-441-0788 ext. 2209 

March 28, 2009 

Fundamentals of Buprenorphine 

Maintenance Treatment 

Centre for Addiction and Mental 

Health (CAMH) 

Toronto, ON 

Contact: Robyn Steidman @ 416- 

535-8501, ext. 6640 

Alternate Tel: 1 800 661-1111 

April 3, 2009 

Diabetes Update 2009 (course 

code BDC0901) 

Banting and Best Diabetes Centre, 

University of Toronto 

Metro Toronto Convention Centre, 

Toronto, ON 

Web: www.cme.utoronto.ca 

Fax: 416-946-7028 

April 17-19, 2009 

Cardiovascular Certificate 

Program 


Toronto, ON 



Tel: 416-441-0788 ext. 2209 

April 25, 2009 

Obesity Level II Certificate 

Program 


Toronto, ON 



Tel: 416-441-0788 ext. 2209 

April 25 and May 9, 2009 

Opioid Dependence Treatment 

Core Education Program 

CAMH Online modules and live 

workshop 

Toronto, ON 

Contact: Robyn Steidman @ 416 535- 

8501, ext. 6640 

Alternate Tel: 1-800-661-1111 

May 2, 2009 

Clinical Workshop – Presentation 

Skills 

Toronto, ON 



Tel: 416-441-0788 ext. 2209 

May 3, 2009 

Clinical Workshop – 

Communication Skills 

Toronto, ON 



Tel: 416-441-0788 ext. 2209 

May 23 and 24 2009 

Infectious Diseases Certificate 

Program 

Toronto, ON 



Tel: 416-441-0788 ext. 2209 

May 25-27, 2009 

A Comprehensive Course on 

Smoking Cessation: Essential 

Skills and Strategies 

Training Enhancement in Applied 

Cessation Counselling and Health 

(TEACH Core course) 

Toronto, ON 

Contact: teach@camh.net or call 

416-535-8501 ext.1600 

May 28-29, 2009 

Tobacco Cessation with 

Aboriginal Populations 



(TEACH Specialty course) 

Toronto, ON 


416-535-8501 ext.1600 

May 28-29, 2009 

Implementing a Systematic 

Approach to Tobacco Dependence 

Treatment for Hospitalized 

Smokers: The Ottawa Mode 



(TEACH Specialty course) 

Toronto, ON 


416-535-8501 ext.1600 

CANADA 

May 5 and 6, 2009 

Advancing Safe Medication 

Practices 

Institute for Safe Medication 

Practices Canada 

Kelowna, BC 

Contact: conferences@ismp-canada. 

org 

Tel: 1-866-544-7672 ext. 226 

continued on page 30 


29

CE resources 

May 30 - June 2, 2009 

Canadian Pharmacists 

Association (CPhA) Annual 

National Conference 

Halifax, Nova Scotia 

Web: www.pharmacists.ca 

E-mail: meetings@pharmacists.ca 

Tel 1-800-917-9489 / 1-613-523-7877 

INTERNATIONAL 

asp?teleconferenceID=50 

High Alert Medication Series: Part 

II: Reducing the Risk of Patient Harm 

from Anticoagulant Therapy 

Centre for Addiction and Mental 

Health (CAMH): April 6, 2009 

http://www.camh.net/education/ 

Online_courses_webinars/index. 

html : 

Drug Information and Research 

Centre (DIRC) 

http://www.opacti.org/ 

Online Clinical Tobacco 

Interventions for Health Care 

Professionals 

http://www.pharmacygateway.com 

On-line CE lessons 

May 10 – 15, 2009 

Clinical Pharmacy in Primary 

Care, Prato, Italy 

Contact: Maria Bystrin @ 

416-978-8458 

Email: cpd.pharmacy@utoronto.ca 

ON-LINE/ WEBINARS 

Institute for Safe Medication 

Practice (ISMP) April 2009 

http://www.ismp.org/ 

teleconferences/default. 

-Fundamentals of Addiction 

-Screening for concurrent disorders 

-Youth & Drugs and Mental health 

http://www.rxcertified.ca 

Online fee-based certificate courses 

developed by the Drug Information 

- Diabetes Patient Care Level 1 

- Obesity Program 

- Women’s Health program 

http://209.200.99.173/vitamin_D 

Vitamin D in Osteoporosis 

http://www.rxbriefcase.com/ 

On-line CE lessons 

http://cpha.learning.mediresource. 

com/select_catalog.asp 

CE lessons on the CPhA Home 

Study Online Learning Centre 


laws & regulations 

Drug and Pharmacies Regulation Act (DPRA) * s 

Amended June 4, 2008 

Regulations to the DPRA: 

DPRA R.R.O. 1990, Regulation 545 – Child Resistant Packages 

DPRA Ontario Regulation 297/96 Amended to O.Reg. 173/08 – General 

DPRA R.R.O. 1990, Regulation 551 Amended to O.Reg. 172/08 – General 

Drug Schedules ** 

Summary of Laws Governing Prescription Requirements, 

Transfers, Refills, Prescription Drug Ordering and Records 

June 2007 OCP 

Canada’s National Drug Scheduling System – 

February 20, 2009 NAPRA (or later) 

Regulated Health Professions Act (RHPA) * s 

Amended November 27, 2008 

Regulations to the RHPA: 

Ontario Regulation 39/02 -Certificates of Authorization Amended to 

O.Reg. 666/05 

Ontario Regulation 107/96 – Controlled Acts 

Ontario Regulation 59/94 – Funding for Therapy or 

Counseling for Patients Sexually Abused by Members 

Pharmacy Act (PA) & Regulations * s 

Amended 2007 

Regulations to the PA: 

Ontario Regulation 202/94 Amended to O.Reg. 270/04 – General 

Ontario Regulation 681/93 Amended to O.Reg. 

122/97 – Professional Misconduct 

Standards of Practice s 

Standards of Practice, January 1, 2003 OCP 

Standards of Practice for Pharmacy Managers, July 1, 2005 

Drug Interchangeability and Dispensing 

Fee Act (DIDFA) & Regulations * s 

Amended June 2007 

Regulations to the DIDFA: 

R.R.O. 1990 Regulation 935 Amended to O.Reg. 354/08 – General 

R.R.O. 1990 Regulation 936 Amended to O.Reg. 205/96 – Notice to Patients 

Food and Drugs Act (FDA) & Regulations ** ' 

Updated as of January 28, 2009 

Amendment 1478 & 1491 – Addition of two medicinal ingredients 

to Part I of Schedule F. Reg. SOR/2007-224, Oct 25/07 

Amendment 1476, 1502, 1511 and 1512 – 

Addition of nine medicinal ingredients to Part I of 

Schedule F. Reg SOR/2007-234, Oct 25/07 

Regulations Amending the Food and Drug Regulations (Project 1551 

- Lanthanum salts) (February 7, 2008) 

Controlled Drugs and Substances Act (CDSA) ** 

Current as of January 28, 2009 

Regulations to the Controlled Drugs 

and Substances Act (CDSA) ** 

All regulations updated January 28, 2009 

Benzodiazepines & Other Targeted Substances Regulations 

Marihuana Medical Access Regulations 

Precursor Control Regulations 

Regulations Exempting Certain Precursors and 

Controlled Substances from the Application of 

the Controlled Drugs and Substances Act 

Narcotic Control Regulations ** 

OCP By-Laws By-Law No. 1 – September 2008 s 

Schedule A - Code of Ethics for Members of the 

Ontario College of Pharmacists - December 2006 

Schedule B - “Code of Conduct” and Procedures for 

Council and Committee Members - December 2006 

Schedule C - Member Fees - Effective January 1, 2009 

Schedule D - Pharmacy Fees - Effective January 1, 2007 

Schedule E – Certificate of Authorization – Jan. 2005 

Schedule F - Privacy Code - Dec. 2003 

Reference s 

OCP Required Reference Guide for Pharmacies 

in Ontario, November, 2008 

Ontario Drug Benefit Act (ODBA) & Regulations * s 

Amended 2007 

Regulations to the ODBA: 

Ontario Regulation 201/96 Amended to O.Reg. 356/08 – General 

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

** Information available at www.napra.org 

' Information available at Federal Publications Inc. Ottawa: 1-888-4FEDPUB (1-888-433-3782) 

Toronto: Tel: (416) 860-1611 • Fax: (416) 860-1608 • e-mail: info@fedpubs.com 

s Information available at www.ocpinfo.com 


31

March/April 2009 • Volume 16, Number 2

Medication Errors & Discipline - Ontario College of Pharmacists

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