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

A Moncton pharmacist has beenfined 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.

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

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

• Pharmacists suspended over mistakes that led to patient deaths
• Pharmacist sentenced to prison in connection with deadly meningitis outbreak

A report issued by the college on Thursday said the coroner foundbaclofenoverdose a contributingfactor in the death of the patient.

Thereport 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 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.

Staff training inadequate

The college found the Ford pharmacy hadno staff training or policy that would have required an independentsecond checkto 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 thecollege's report.

"When dealing with medication there should be cross-checks, not justwith the person who dispensesthe 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."

Cassistasaid special care homesare also not required to have medical staff on duty, so a personal care worker administers the medications. As a result, shesaid, 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.