College calls drug-dispensing mistake that led to patient's death a 'rare' case

An error in drug dispensing could go unnoticed if a patient or caregiver doesn't catch it in time, the New Brunswick College of Pharmacists says.

"A lot of the errors, they can go unnoticed," said SamLanctin, registrar of the New Brunswick College of Pharmacists, which recently reported a serious dispensing mistakeby a Moncton pharmacy.

Last week,the college announced it had fined and reprimanded the pharmacist for what Lanctin called a rare incident. Someone on staff at Ford'sFamily Pharmacy & Wellness Centre had made an error that led to the death of a patient in long-term care.

The pharmacydispensed a muscle relaxant at fivetimes the concentration on the label.

• Monctonpharmacist fined for drug-dispensing mistake that led to patient's death

Although he didn't make the error himself, manager Peter Ford was reprimanded and fined $5,000 and ordered to pay $8,000 for the costs of the investigation and complaint process.

Lanctin said this "worst case scenario"isn't seen often.

The incidentwas brought to the college's attention near the end of 2015 bythe pharmacy itself, as required by law.

It's important we try to build those extra layers to make sure we avoid these mistakes and we have several sets of eyes on these processes and try to eliminate them.-SamLanctin, registrar of the New Brunswick College of Pharmacists

"It was brought to the pharmacy's attention by the caregiver at the long-term care home that noticedthe liquid, the suspension that was given to the patient, looked different than usual and so they addressed it to the pharmacy," he said.

"It's a very rare incident when you consider the millions of prescriptions that are dispensed in New Brunswick in the run of a year."

From there, the college sent in an inspector to gather information. Meanwhile, a member of the deceased patient's family lodged a complaint to the college.

Quality assurance needed

The college said the errorwas 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 ofbaclofeninstead of 2 mg/mL.Pharmacists use compounding sheets when theymix the ingredients in a medication according to an individual patient's prescription.

Although uncommon,Lanctinsaid an error like this can still happen if there aren't quality-assurance programs, including double-checking by different individuals,in place.

"It's important we try to build those extra layers to make sure we avoid these mistakes, and we have several sets of eyes on these processes and try to eliminate them," he said.

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

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

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."

Lanctin said Ford has accepted responsibility and put the college's recommendations into effect.

"We're following up with him on a regular basis and we'll be in there to help him along with those recommendations to make sure they get implemented," said Lanctin.

Lessons learned

The college said it was sharing the findingsof the investigation not just with Ford's pharmacy but other pharmacies across the province as well.

"We learn from these mistakes and that's got to be the silver lining in this," he said.

He said this is a good opportunity for pharmacists to look at their own pharmacies.

"Pharmacies don't want this and we're working at improving the system."

Pharmacist Peter Ford did not wish to comment.