Moncton pharmacist fined for drug-dispensing mistake that led to patient’s death

A Moncton pharmacist has been fined and reprimanded by the New Brunswick College of Pharmacists after someone on his staff made a dispensing error that led to the death of a patient in long-term care.

The New Brunswick College of Pharmacists says it found Ford’s Pharmacy was not practising up to standard when a staff member mixed a drug in the wrong concentration and the error led to a patient’s death. (Graeme Roy/Canadian Press

Although he didn’t make the error himself, Peter Ford, manager of Ford’s Family Pharmacy & Wellness Centre, was fined $5,000 for dispensing baclofen suspension, a muscle relaxant, at five times the concentration on the label.

The medication is used to treat spasticity, a muscle condition.

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A report issued by the college on Thursday said the coroner found baclofen overdose a contributing factor in the death of the patient.

The report didn’t say when the dispensing error was made or when the patient died.

An investigation was launched after a complaint from a member of the public, the college said.

The drug was administered for seven days until a nurse in the patient’s long-term care home realized the suspension appeared to be different from the previous preparation, the college said.

Reprimanded for ‘laxity’

In addition to the fine, Ford was penalized $8,000 for the costs of the investigation and complaint process. The account of the error will remain on his file for two years.

The reprimand said the college considered Ford’s “initial laxity in managing quality assurance measures and subsequent inaction to address them to be an abrogation of responsibility to patient wellbeing.”

A complaints committee blamed the error on a lack of safety systems and not a single employee.

The college said the error was made in the “compounding suite,” when a Ford staff member selected an incorrect compounding sheet to prepare the patient’s prescription — a sheet for a 10 mg/mL concentration of baclofen instead of 2 mg/mL. Pharmacists use compounding sheets when they mix the ingredients in a medication according to an individual patient’s prescription.

Staff training inadequate

The college found the Ford pharmacy had no staff training or policy that would have required an independent second check to ensure the selected compounding sheet matched what the prescription required.

The investigation also found that near-miss incidents at the pharmacy were not being recorded, which made it impossible to determine whether the same kind of error had happened before.

Although an investigator suggested the Ford pharmacy use a tool for tracking errors and near misses, its use declined over a year, the college said.

“Dr. Ford and his staff expressed remorse and took responsibility,” the report said.

​The New Brunswick College of Pharmacists did not want to discuss the report with CBC News, and Ford declined an interview.

Cecile Cassista, executive director of the Coalition for Seniors and Nursing Home Residents’ Rights, was shocked by the college’s report.

“When dealing with medication there should  be cross-checks, not just with the person who dispenses the medication but someone also in charge of a shift in question,” she said.

“I have seen quite often staff change in many drug stores and question if their work is being double-checked for errors.”

Cassista said special care homes are also not required to have medical staff on duty, so a personal care worker administers the medications. As a result, she said, more needs to be done to prevent dispensing errors, and the public needs to be made aware they’re possible.

“I also believe that even someone picking up their prescription at the pharmacy, it should be reviewed upon pickup to ensure it meets the request of the prescription,” she said.

Source:cbc.ca/news