July • August 2003 - Ontario College of Pharmacists

DISCIPLINE
CASE 3
Failure to Ensure That Appropriate Systems Were in
Place to Assure Accurate Delivery of Medication to A
Patient; Failure to Appropriately Dispose of Drugs
Returned to Stock
Member: Gerald Friesen, Thunder Bay
Hearing Date: March 14, 2003
Mr. Friesen was found to have:
• Failed to maintain a standard of practice of the profession
• Returned to stock or again sold or dispensed a drug previously
sold or dispensed and delivered
• Engaged in conduct or performed an act relevant to the
practise of pharmacy that, having regard to all the circumstances,
would reasonably be regarded by members as
disgraceful, dishonourable or unprofessional
The following Agreed Statement of Fact formed the
basis of Mr. Friesen’s admission of professional misconduct.
Facts
A pharmacist at Mr. Friesen’s pharmacy filled a prescription
for 100mL Hydrocortisone suspension 1mg/mL (a
compound prescribed for congenital adrenal hyperplasia)
for a child patient. The prescription was then placed in a
refrigerator for delivery the next day. The dispensing pharmacist
also filled a prescription for Methadone for another
client, which was stored in the same refrigerator as the
Hydrocortisone compound.
In error, the Methadone was packaged for delivery to
the child instead of the Hydrocortisone compound. The
child’s mother received the package, poured the medication
into a teaspoon and was about to administer the medication
to the child when she noticed by its content that it was not
the correct medication. She then read its label which indicated
that the medication was Methadone prepared for
another patient. The mother notified the pharmacy
regarding the packaging error. Mr. Friesen personally delivered
the Hydrocortisone compound to the mother and
retrieved the Methadone.
Mr. Friesen returned to the pharmacy and placed the
Methadone back in the refrigerator. He did not set the
bottle aside or take other precautions to ensure that the
Methadone was not re-dispensed to the wrong patient. The
Methadone was relabelled to reflect the day’s date and was
then dispensed to the patient it was intended for.
Reasons
The Committee believes the Joint Submission on Penalty
was appropriate for the following reasons:
• Mr. Friesen pleaded guilty and immediately accepted
responsibility for the errors, saving the College undue
cost and expense of investigation
• In 34 years of practice in Ontario, this was Mr.
Friesen’s first appearance before the Discipline
Committee
• The initial packaging error was made by an unknown
pharmacy employee and Mr. Friesen, as the designated
manager, accepted responsibility for the error
• Mr. Friesen accepted full responsibility for returning
to stock and re-dispensing the Methadone solution
• Prior to the hearing, Mr. Friesen, on his own accord,
attended and completed the Methadone Treatment
Workshop provided by the Centre for Addiction and
Mental Health. The workshop included seven hours of
instruction, including the fundamentals of methadone
maintenance, counselling of methadone patients, pharmacy
issues, urine drug screens and an overview of
substance use disorders
• While there was potential for patient harm, none in
fact occurred
• Mr. Friesen has modified his practice by designating a
separate refrigerator for storing methadone
The panel notes that dispensing errors concerning
methadone, as well as other narcotic and controlled
substances, may lead to very serious consequences and
urges the member to exercise extreme caution when
dispensing these substances.
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Pharmacy Connection July • August 2003