Controlled Drug Record-Keeping Failures Lead to 6-Month Suspension for NI Pharmacist

Date of Decision: August 12, 2013

Registrant's Role: Pharmacist

Allegations:

• The registrant instructed a locum pharmacist to supply a Controlled Drug that had already been assembled and entered into the Controlled Drug Register without a valid prescription being available (Patient A).
• The registrant instructed a locum pharmacist to dispense Methadone, a Controlled Drug, to a patient who was not accompanied as required by the prescription (Patient B).
• The registrant failed to properly complete Patient Medication Records (PMR) for a patient receiving Suboxone in that:
• (a) Records were not always made following the dispensing of a valid prescription.
• (b) Records did not accurately reflect the dates of supply endorsed on corresponding prescriptions (Patient C).
• The registrant failed to dispense Diazepam in accordance with the prescribing physician’s instructions (Patient D).
• The registrant failed to dispense Diazepam on set days when directed to dispense twice weekly, contrary to the prescribing physician’s expectations and best practice (Patient E).
• The registrant failed to:
• (a) Maintain an accurate and contemporaneous record in the Controlled Drug Register of the supply of Fentanyl patches (Patient F).
• (b) Follow dispensing directions as authorised by the prescribing physician (Patient F).

Outcome: Suspension for 6 months, with a review prior to expiry.

GPhC Standards Breached:

• Standard 1 – Make the safety and wellbeing of patients your first priority
• Standard 6 – Behave in a professional manner
• Standard 8 – Speak up when you have concerns or when things go wrong
• Standard 9 – Demonstrate leadership

Case Summary