July • August 2003 - Ontario College of Pharmacists

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