Pharmacist’s Extensive Controlled Drug Errors and Unsafe Dispensing Lead to Conditions Order

Date of Decision: July 3, 2018

Registrant's Role: Pharmacist

Allegations:

• Between August 2016 and February 2017, the registrant worked at a community pharmacy and demonstrated repeated failures in handling and recording Controlled Drugs (CDs).
• Failed to accurately record supply of MST (morphine sulfate) 15mg modified-release tablets.
• Supplied incorrect strengths of MST and made incorrect CD register entries, including incorrect balances.
• Failed to correct CD register errors.
• Supplied incorrect quantities of methadone and dispensed against an expired prescription.
• Supplied incorrect methadone quantities and inaccurately recorded them in the CD register.
• Behaved aggressively towards a manager during a workplace discussion.
• Failed on multiple occasions to make accurate CD register entries for methadone (missing or incorrect patient, prescriber, date, ID, and pharmacist details).
• Dispensed incorrect strength morphine capsules and failed to update CD register after correction.
• Supplied incorrect strength and quantity of Zomorph and failed to record in CD register.
• Failed to maintain accurate CD records for Zomorph on multiple occasions.
• Incorrectly recorded receipt of Matrifen patches, leading to inaccurate CD balance.
• Supplied Concerta XL against an expired prescription.
• Failed to record delivery of Zomorph capsules.
• Incorrectly recorded Concerta supply in CD register.
• Supplied buprenorphine with incorrect labelling (200mcg labelled as 2mg).
• Failed to record delivery of Zomorph CDs.
• Incorrectly labelled Equasym XL capsules.
• Failed to accurately record multiple CD supplies including Concerta, Tranquilyn, and Sevredol.
• Failed to securely store CDs (Concerta XL not kept in locked cabinet).
• Poor dispensary management including unrecorded CDs, unattended stock, and incomplete documentation.

Outcome: A conditions of practice order was imposed for 9 months, alongside an interim conditions order.

GPhC Standards Breached:

• Standard 1.6 – Do your best to provide medicines and other professional services safely and when patients need them
• Standard 1.8 – Keep full and accurate records of the professional services you provide in a clear and legible form
• Standard 6.6 – Comply with legal and professional requirements and accepted guidance on professional practice
• Standard 6.9 – Promptly tell relevant authorities about anything that may affect your fitness to practise
• Standard 7.6 – Ensure appropriate standard operating procedures are in place and followed
• Standard 7.7 – Ensure workload or working conditions do not present a risk to patient care or public safety

Case Summary

Original Case Document