Pharmacists suspended over mistakes that led to patient deaths

A pair of Nova Scotia pharmacy managers have been suspended after making prescription drug dispensing mistakes in unrelated cases that ultimately led to the deaths of two patients.

The Nova Scotia College of Pharmacists also says one of the pharmacists, Alexandra Willson, misled authorities following the mistake and falsely declared she had implemented a quality assurance program.

The professional misconduct suspensions against Willson and another pharmacist, Leanne Forbes, came following settlements with the college's investigation committee. The locations of their pharmacies were blacked out in the written decisions released by the college.

Willson's suspension is for two months after she acknowledged a prescription mistake on May 3, 2016, that led to a patient being admitted to hospital three weeks later with severe infections. The patient died on June 16.

Failed to be diligent

A pharmacy assistant had wrongfully placed 1.5 tablets of methotrexate in individual compartments, one for each day of the week, according to the investigation committee.

Methotrexate is an immune system suppressant and the patient was only supposed to take one tablet a week. Willson did note the error and asked her assistant to remove the extra tablets but did not recheck them.

Only half the tablets were removed.

"You failed to be diligent in taking the necessary steps to determine the accuracy of a prescription prior to dispensing it to the patient," says the decision.

Willson now has to pay $7,500 of the regulator's costs as well as a fine of $5,000.

'Falsely declared' issue corrected

The decision states Willson did not notify the Canadian Pharmacy Incident Reporting Program about the matter, as required, and did not address the same mistake by the assistant a month earlier.

"This deficiency was identified in previous pharmacy inspections," says the decision.

The committee also says Willson "falsely declared" the issue was corrected and that she had implemented a "continuous quality assurance program." She had not.

The decision went on to state 12 audits will be performed at any pharmacy where Willson works, she must complete a quality assurance course offered by the college and must contact the patient's family to apologize.

Patient died of methadone intoxication

In the Forbes case, she agreed to a 30-day suspension after the college found she did not properly determine the "appropriateness of a drug therapy" for a patient.

In November 2015, a patient provided Forbes a prescription for methadone and naltrexone but only the methadone was dispensed.

The college says Forbes failed to tell the individual that ceasing to take naltrexone was very risky. The patient died on Dec. 3, 2015.

"The medical examiner's report states that methadone intoxication was the cause of death," the committee says, and that the patient died because naltrexone was withdrawn.

Forbes must also pay the regulator $7,500 and deliver an apology to the family.

She must take part in staff meetings concerning drug interactions, take a course in methadone and be the subject of practice audits.