September/October 2009

Progress Report on Regulation of Pharmacy Technicians

page 8

Documenting Dialoguepage 15

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Council Members

Council Members for Districts 1-17 are listed below according to District number. PM indicates a public member appointed by the Lieutenant-Governor-in-Council. DFP indicates the Dean of the Leslie Dan Faculty of Pharmacy, University of Toronto. DSP indicates the Director, School of Pharmacy, University of Waterloo.

1 Joseph Hanna2 Elaine Akers3 Sherif Guorgui4 Tracey Phillips5 Donald Organ6 Fayez Kosa7 Tracy Wiersema8 Saheed Rashid9 Bonnie Hauser10 Gerald Cook11 Christopher Leung12 Peter Gdyczynski13 Sanjiv Maindiratta14 Stephen Clement15 Gregory Purchase16 Doris Nessim17 Shelley McKinney

PM Joinal AbdinPM Thomas Baulke PM Corazon dela CruzPM Babek Ebrahimzadeh PM David HoffPM Margaret Irwin PM Javaid KhanPM Lewis LedermanPM Aladdin MohagheghPM Gitu ParikhDFP Wayne HindmarshDSP Jake Thiessen

Statutory Committees• Executive • Accreditation• Complaints • Discipline • Fitness to Practice • Patient Relations• Quality Assurance • Registration

Standing Committees• Communications• Finance • Professional Practice

Special Committees• Standards of Practice Working Group • Pharmacy Technicians Working Group

College Staff

Office of the Registrar and Deputy Registrar/Director of Professional DevelopmentPharmacy Connection Editor x [email protected]

Office of the Director of Finance and Administration x [email protected]

Office of the Director of Professional Practice x [email protected]

Registration Programs x [email protected]

Structured Practical Training Programs x [email protected]

Investigations and Resolutions x [email protected]

Continuing Education Programs andContinuing Competency Programs x [email protected]

Pharmacy Openings/Closings,Pharmacy Sales/[email protected]

Registration and Membership Information:[email protected]

Pharmacy Technician Programs:[email protected]

Publications x [email protected]

ontario college of pharmacists483 Huron Street, Toronto, Ontario M5R 2R4 • Tel (416) 962-4861 • Fax (416) 847-8200 • www.ocpinfo.com

The mission of the Ontario College of Pharmacists is

to regulate the practice of pharmacy, through

the participation of the public and the

profession, in accordance with standards of

practice which ensure that our members

provide the public with quality

pharmaceutical service and care.

July • August 2008 Volume 15 • Number 4

The objectives of Pharmacy Connection are to communicate information on College activities and policies; encourage dialogue and to discuss issues of interest with pharmacists; and to promote the pharmacist’s role among our members, allied health professions and the public.We publish six times a year, in January, March, May, July, September and November. We welcome original manuscripts (that promote the objectives of the journal) for consideration. The Ontario College of Pharmacists reserves the right to modify contributions as appropriate. Please contact the Associate Editor for publishing requirements.We also invite you to share your comments, suggestions, or criticisms by letter to the Editor. Letters considered for reprinting must include the author’s name, address and telephone number. The opinions expressed in this publication do not necessarily represent the views or official position of the Ontario College of Pharmacists.

Tracy Wiersema, R.Ph., B.Sc.Phm.President

Deanna Williams, R.Ph., B.Sc.Phm., C.Dir., CAE Registrar

Della Croteau, R.Ph., B.S.P., M.C.Ed.Editor, Deputy Registrar,Director of Professional [email protected]

District Meetings 2009 7

Regulation of Pharmacy Technicians - Progress Report 8

The Ontario Physician Assistant Initiative 13

Documenting Dialogue 15

Elder Abuse 17

An update on the e-Prescribing project 18

Partnership in Lung Age Testing & Education Programme 24

Inspector’s Corner - Action Plans 26

regular featuresEditor’s Message 4

Registrar’s Message 5

Council Elections 6

SPT Q&A 20

Health Canada Notices 21

Registration Q&A 22

Bulletin Board 23

Update on Technology 25

ISMP 28

Practice Q&A 30

Deciding on Discipline 31

Focus on Error Prevention - DIN Billing Error 37

CE Resources 38

Laws & Regulations 39

pharmacyconnectionSeptember/October 2009 Volume 16 • Number 5

Technician Regulation – page 8

District Meetings 2009 – page 7

Asthma Society of Canada – page 24

contents

Sue RawlinsonAssociate [email protected]

Agostino PorcelliniProduction & Design / [email protected]

Neil Hamilton [email protected]

ISSN 1198-354X© 2009 Ontario College of Pharmacists

Canada Post Agreement #40069798Undelivered copies should be returned to the Ontario College of Pharmacists.Not to be reproduced in whole or in part without the permission of the Editor.

Della Croteau, R.Ph., B.S.P., M.C.Ed.Deputy Registrar/Director of Professional Development

4 pharmacyconnection • September/October 2009

Regulation of pharmacy tech-nicians will soon be a real-ity in Ontario! The first pilot

of the Pharmacy Examining Board of Canada Examinations was held at the end of August, and this group of ground-breaking technicians are finishing off their final requirements

for registration while they await the exam results. And there are hun-dreds more pharmacy technicians who have begun their education and preparation for registration. I ac-knowledge all these pharmacy tech-nicians and their employers for em-bracing this change and for piloting the various processes for registra-tion as we work out all the kinks.

There has been a tremendous amount of work that has been done in the last three years to realize the goal of the College in regulating Pharmacy Technicians. Many phar-macists, pharmacy technicians and pharmacy technician educators have

spent long hours consulting and de-veloping curricula, assessments, standards and examinations in order for this monumental event to occur.

This edition of Pharmacy Con-nection gives a good overview of all the processes involved in the regis-tration of Pharmacy Technicians,

and is an excellent update on where we are in the registration process. I encourage all pharmacists and pharmacy technicians to familiarize themselves with the processes and the information provided.

The College is pleased to have worked collaboratively with other provincial and national stakeholders develop national competencies for pharmacy technicians, national ac-creditation standards for pharmacy technician education programs, na-tional f luency standards and a na-tional entry to practice examination for pharmacy technicians. This will enable common standards across

Canada, and lay the groundwork for labour mobility of pharmacy techni-cians once other provinces begin to regulate technicians as well.

Ontario pharmacists will soon have an accountable and responsible partner in the registered pharmacy technician, which will enable phar-macists to take on a greater role in patient care in a collaborative en-vironment as proposed in legisla-tion in Ontario. For an update on the advancing practice of both phar-macy technicians and pharmacists, plan to attend the District meetings across the province this fall. Your input and feedback in these discus-sions is vital as the College moves forward to develop regulations, standards and guidelines which will outline the terms and conditions under which pharmacists and phar-macy technicians will be expected to practice.

Ontario pharmacists will soon have an accountable and responsible partner in the registered pharmacy technician, which will enable pharmacists to take on a greater role in patient care in a collaborative environment as proposed in legislation in Ontario.

editor’s message

5pharmacyconnection • September/October 2009

Deanna Williams, R.Ph., B.Sc. Phm., C.Dir., CAERegistrar

“They were good times…..they were challenging times….” How often these

words have applied to our profes-sion. And they certainly apply today.

As the government undertakes yet another Drug System Renew-al initiative in Ontario, they have, in tandem, introduced Bill 179 - a sweeping piece of legislation that will expand the scopes of practice of a number of health professions in-cluding pharmacy.

Third and final reading of the Bill is expected in the fall, and the Col-lege has been working over the sum-mer months to ensure that the legis-lative and regulatory framework is in place to permit pharmacists in Ontario to fully realize your roles in monitoring and managing medica-tion therapy.

The pharmacist’s unique role in medication monitoring and manage-ment is now recognized in the new,

proposed scope of practice state-ment for Pharmacy.

The addition of four new, con-trolled acts - prescribing, adminis-tration of substances by injection and inhalation, and performing a procedure on tissue below the der-mis - will be performed under terms, conditions and limitations that en-able your role in managing and mon-itoring medication therapy in the spirit of inter-professional collabora-tion and care. The proposed terms

and conditions for prescribing will permit you to adapt, modify or ex-tend existing prescriptions based as always, on principles of sound pro-fessional judgement; actions taken in the best interest of the patient; and documentation and communi-cation of actions taken in a timely manner back to the primary care practitioner.

Administration of substances by injection or inhalation will now

enable you to prick a patient’s fin-ger when educating your patients/their agents in the use of blood monitoring devices or inhalant de-vices through demonstration and to teach, through demonstration, new diabetic patients how to self inject their insulin. While providing rou-tine injections is not currently con-templated, the addition of the new controlled act of performing a pro-cedure on tissue below the dermis would also permit a pharmacist- but ONLY if properly trained to do so- to give injections- such as f lu shots in a pandemic- if necessary.

The over-riding principle for all activities within the revised scope of practice remains the same for all professionals - you only do what you know - or ought to know - you have the training, knowledge and ability to do. In other words, while the re-vised scope of practice will apply to all pharmacists in Ontario this over-riding principle is key.

We know that some pharmacists in Ontario, while able to work with-in the revised scope of practice, will not feel comfortable doing so-this is okay. Alternatively, pharmacists al-ready working within an expanded

registrar’s message

The College wants the profession to be successful in embracing the revised scope and the regulations will include the terms, conditions and limitations that Council believes is appropriate, comfortable and do-able by the profession.

scope- through medical directives or delegation - may feel the College is being too cautious and setting terms and conditions that are too restrictive. But the College’s man-date for public protection neces-sarily guides Council in determining what the parameters for the new scope of practice should be.

The College wants the profes-sion to be successful in embracing the revised scope and the regu-lations - which still need to be

developed and circulated to give ef-fect to the new scope of practice- will include the terms, conditions and limitations that Council believes is appropriate, comfortable and do-able by the profession. In late Sep-tember through early November we will be holding District meetings around the province to share with you more details respecting the re-vised scope and updates respect-ing labour mobility provisions and pharmacy technicians regulation.

Meetings provide the opportun-ity for you to hear from us, but most importantly, for us to hear from you - to fully understand your questions and concerns. Please check the schedule on the follow-ing page for a listing of the meeting nearest you and plan to attend.

Webcasts are also planned for those who are unable to attend a meeting in person. Hope to see you soon!


registrar’s message

MS. ZITA SEMENIUK, DISTRICT 6

Congratulations!

Please also note that a by-election will be held in District 15 and a call for nominations will be sent to all members in that district shortly.

CouncilElections

CouncilElections


Given the extent and nature of new and emerging issues, the College will be holding district meetings this fall at

various venues throughout Ontario to discuss pharmacy technician regulation, the proposed new scope of practice

for pharmacists, and remote dispensing.

All meetings will be held in the evening from 7:00 p.m. to 9:00 p.m. Pharmacists and pharmacy technicians are

strongly urged to attend a district meeting, as there will be information and discussion of interest to everyone

(registration is not required).

Specific locations are published on our website (www.ocpinfo.com).

We hope that you will be able to join us at one of these meetings.

If you have any questions concerning these meetings, please contact Louise Todd, at 416-847-8241 or

by email at [email protected].

CITY DATE

Toronto Tuesday, September 22

Ottawa Wednesday, September 30

Cambridge Wednesday, September 30

Belleville Thursday, October 1

Thunder Bay Thursday, October 1

Sudbury Tuesday, October 6

Windsor Tuesday, October 6

North Bay Wednesday, October 7

London Wednesday, October 7

Sault Ste. Marie Wednesday, October 14

Brampton Wednesday, October 14

Scarborough Thursday, October 15

Mississauga Thursday, October 15

Hamilton Wednesday, October 21

GTA Hospital Pharmacists Wednesday, October 21

St. Catherines Thursday, October 22

Barrie Tuesday, October 27

Toronto Wednesday, October 28

T8 pharmacyconnection • September/October 2009

pharmacy technician

Regulation of Pharmacy Technicians

he development and implemen-tation of the processes and programs needed to regulate pharmacy technicians in On-tario has progressed well over

the last year, and it won’t be long now before the College is able to register the first group of pharmacy technicians in Ontario. There has been continued commitment and a strong response from pharmacy technicians and their phar-macist colleagues as each new component is introduced. The College regrets that we have not been able to accom-modate the overwhelming interest in the early stages of implementation, but we remain confident that access to the required programs will be widely available by the end of this year. Final development and pilot testing of each of the entry-to-practice activities will occur this fall and full implementation will start in 2010.

As each new program or activity has been introduced there has been increased interest in the initiative and more people trying to decide how it all applies to them. The decision to become registered is one that all pharmacy

FALL 2009 PROGRESS REPORT


technicians are free to make, and will need to make in the near future. While many have already chosen to pursue registration, there are others still trying to decide. For these individuals there are two key questions to address; what is involved in becoming registered and what bene-fit will I gain?

The answer to how to become registered is one the College can address. The chart below has been developed to outline the basic steps to follow. The information that follows the chart provides current details about each of these requirements.

The question about why to become registered is much more complex because the answer is unique to each in-dividual’s situation. Although there are a variety of con-tributing factors to consider, one of the most important will be the impact of regulation within your workplace. Many employers have started to determine their future human resource needs and are discussing their expecta-tions with staff, a dialogue the College encourages at this time. An understanding of your employer’s perspective, along with the information presented below about the

requirements to become registered will go a long way in helping you make an informed decision.

The first step in understanding the requirements is to determine which category or stream you need to follow (In the profession or Entering the profession) because the first two requirements are different.

You are considered to be in the profession if:• You graduated from any pharmacy technician educa-

tion program prior to 2008• You have been trained on the job and are performing

the role of a pharmacy technician• You graduated in 2008 or later from an education pro-

gram that did not have provisional accreditation status from the Canadian Council for Accreditation of Phar-macy Programs (CCAPP) when you graduated (Go to www.ocpinfo.com> pharmacy technicians>CCAPP accreditation to see the list of programs.)

• You have a pharmacy degree from another country and have been working as a pharmacy technician in Ontario (Canada)


You are considered to be entering the profession if:• You graduated in 2008 or later from a pharmacy tech-

nician education program that held a provisional ac-creditation from CCAPP when you graduated. (Go to www.ocpinfo.com>pharmacy technicians>CCAPP accreditation to see the list of programs).

Step 1For those currently in the profession:You must have successfully completed the OCP certifica-tion exam (discontinued after October 2008) or complete the Pharmacy Examining Board of Canada (PEBC) Evalu-ating Exam (available twice annually, starting in October 2009). Please note that PEBC has set a 2000 hour prac-tice requirement to establish eligibility to sit the evaluating exam. Further details about the exam can be found on the PEBC website at www.pebc.ca. All applicants should note that the College has proposed in the Registration Regula-tion that this step must be completed by January 1, 2012 to be eligible for registration in Ontario.

For those entering the profession:You must graduate from a pharmacy technician program that held provisional or full accreditation status from CCAPP when you graduated. To confirm if you meet this criteria check the list of CCAPP accredited schools, avail-able at www.ccapp_accredit.ca or on the OCP website.

The College recommends that anyone who is planning to enter the profession now or in the future enroll in a pro-gram that has achieved provisional accreditation status if they wish to ensure eligibility for registration with the College. If you are enrolled in a program with qualifying status, be aware that there is no guarantee the program will achieve provisional accreditation status prior to your graduation. In the event your program does not achieve the necessary accreditation status you will be required to meet the same requirements as those currently In the profession. You should note that this includes completion of the PEBC evaluation exam (which has a 2000 hour practice requirement for all applicants) by January 1, 2012.

Step 2For those currently in the profession:You must complete the Bridging Education Program for Pharmacy Technicians. This 150 hour continuing edu-cation program is comprised of 4 courses (Professional Practice, Pharmacology, Management of Drug Distribu-tion and Product Preparation) and a structured practical evaluation in the workplace to demonstrate competent performance of the independent double check (commonly known as tech-check-tech).

Although the Bridging Education Program is manda-tory for everyone in this stream, three of the four courses may be completed through a prior learning assessment. The Professional Practice course must be completed by everyone. Prior learning assessment involves completion of a challenge exam, which allows the individual to dem-onstrate they already have the knowledge and skill needed to meet the learning outcomes for the course. Registration for a prior learning assessment may be completed at any of the Colleges offering the Bridging Education Program. In-dividuals who request a prior learning assessment and are not successful will be required to complete the full course.

The structured practical evaluation of the independ-ent double check will be completed in the workplace, fol-lowing completion of the Drug Distribution and Man-agement course. The College is responsible for adminis-tration of this evaluation, which will be piloted this fall. This evaluation will be similar to the existing “tech check tech” certification completed in most hospitals, but will allow pharmacy technicians in all practice environments to demonstrate competency in this task. More details will follow after the pilot.

For those entering the profession: After completion of a CCAPP accredited program, gradu-ates will be required to complete a period of Structured Practical Training (SPT). This program will provide an opportunity for the individual to demonstrate perform-ance of the entry-to-practice competencies in the practice environment. The training program must be completed

pharmacy technician


in an approved practice site and under the supervision of an approved preceptor.

Similar to internship for pharmacists, a number of struc-tured activities, ref lective of the entry-to-practice com-petencies, must be completed and assessed by the individ-ual and their preceptor. Evaluation of the “independent double check” as described above will be one of the struc-tured activities included in the SPT program. An initial pilot of this program will be completed this fall, including implementation of an on-line format for documentation of the activities and assessments. Training for preceptors of pharmacy technicians will also be provided by the Col-lege. Although preceptors will be pharmacists at the out-set of the program, once pharmacy technicians become registered they will also be able to serve as preceptors.

Step 3 For everyone entering the professionAll individuals pursuing registration with the College must successfully complete the PEBC Qualifying Examina-tion. This national exam has two components; a written

multiple-choice question exam (MCQ) and a practical exam called an objective structured performance exam (OSPE). The exam blueprint is based on the National As-sociation of Pharmacy Regulatory Authorities (NAPRA) Professional Competencies for Canadian Pharmacy Tech-nicians at Entry to Practice.

The Qualifying Exam is presently being piloted in On-tario and will become available at multiple sites across the province and in other provinces next summer. PEBC anticipates completing a second pilot of the exam in the spring, 2010 however details are not yet available.

Individuals who have successfully completed step one, as described above, will be eligible to sit the Qualifying Exam. Individuals who are also completing the Bridging Education Program are advised to do so prior to complet-ing the Qualifying Exam. Bridging courses will provide a good opportunity to establish readiness for the exam. In the event individuals complete the PEBC Qualifying Exam before finishing the Bridging Program, the courses will still need to be completed as they address learning and as-sessment components that are different from the exam.

The Bridging Education Program

was initiated in the fall of 2008 with

the introduction of the Professional

Practice course. Pharmacology was

added in the winter 2009 session

and Drug Distribution in the

spring/summer semester. The final

course, Product Preparation will be

implemented this fall. Over 1500

people have started to complete the

Bridging Courses and many more

have been waiting for delivery in

their community. We would like to

thank everyone involved for their

support and patience during the

early stages of implementation.

Eight of the CCAPP accredited

community colleges are now

offering the Bridging Education

Program. Many satellite locations

and affiliated college agreements

have been established and will

continue to evolve in order for these

community colleges to offer the

program throughout the province.

In addition, each of the courses will

be available in an on-line format

through Ontario Learn, starting in

September 2009. Registration for

all delivery formats (classroom, on-

line and prior learning assessment)

is available through any one

of the accredited community

colleges. Registration and contact

information is maintained on the

College website at www.ocpinfo.

com>pharmacy technicians>bridging

education. If you would like to

inquire about establishing delivery

of the courses in your local

community, you may contact any

one of the approved Colleges.

Update on Delivery of the Bridging Education Program


More details about the exam are available on the PEBC website at www.pebc.ca.

Step 4For everyone entering the professionAll individuals pursuing registration with the College must complete the OCP Pharmacy Technician Jurisprudence Examination in order to demonstrate they possess the knowledge necessary to practice according to the laws of the profession. Similar to the jurisprudence exam for pharmacists, it is a multiple-choice exam administered by the College in multiple sites. A pilot of this exam will take place in the fall and regular administration will be avail-able by spring 2010.

Step 5For everyone entering the professionAfter meeting each of the previous steps, individuals will be ready to complete their application for a certificate of registration with the College. At this stage, the College will also verify that the individual meets all other require-ments for registration, such as demonstration of language proficiency and good character, as required to practice the profession safely, ethically and professionally.

The College worked in partnership with NAPRA this summer to host a national workshop with pharmacy tech-nicians and pharmacists to consider national language pro-ficiency requirements for pharmacy technicians. Results from the workshop will be presented to the NAPRA board this fall with a recommendation for national pharmacy technician standards for objective language proficiency tests.

Applicants will be required to complete a declaration of good character which includes disclosure of any past criminal offences or f indings related to the practice of pharmacy or any other regulated profession. Any con-cerns related to the individuals competence, conduct or capacity to practice the profession will be considered by a panel of the Registration Committee.

pharmacy technician

The Bridging Education Program offers a great

opportunity for you to share your knowledge and

experience with colleagues who are preparing

to practice in their new role as regulated health

professionals. Qualified instructors are needed

to assist in delivery of the Bridging Education

Program for classroom delivery in communities

throughout the province and through the on-line

format.

If you have teaching experience and are

interested in contributing to the initiative to

regulate pharmacy technicians, you are invited

to apply to any one of the Community Colleges

currently offering the Bridging Education Program.

Check the College website (www.ocpinfo.com.>ph-

armacytechnicians>Bridging Program>Registration

details) to see where these Community Colleges

are currently offering courses, or contact them to

explore your interest in establishing delivery in

your community if it does not already exist.

Each of the four required courses is between

33 and 45 hours in length and may be offered

in a variety of schedules (e.g. regularly weekly

classes or condensed delivery models). Curriculum

development has been completed so that

instruction manuals and course materials are

available to support consistent delivery of the

program across the province. Current instructors

have reported that this is rewarding and refreshing

way to contribute to the profession and engage in

their own professional development in the process!

Teaching Opportunities Available!


physician assistant

he Physician Assistant (PA) role was introduced as part of the Ontario government’s health human resour-ces strategy in 2006 and has been

launched into the Ontario health care system through two phases. Phase One began in January 2007 and was an emergency department (ED) demonstration project in which PAs, nurse practitioners, and acute care nurse spe-cialists joined the ED teams of six hospitals. Positive evalu-ation findings of this Phase One project included shorter wait times; shorter stays in EDs and fewer patients leav-ing the ED without being seen. Due to these positive re-sults, these positions were extended beyond this initial demonstration project.

Phase Two consists of a series of two-year demonstra-tion projects taking place in a variety of health care set-tings. PAs are currently working as part of interprofes-sional teams in hospitals, primary care community health centres, long-term care facilities, and diabetes care set-tings and are expected to begin working in family health teams (FHTs) shortly. There are approximately 60 PAs currently working in the field across Ontario. A compre-hensive evaluation of the PA role is underway and the re-sults will inform future decisions about the integration of the PA role in Ontario.

PAs have practised in the United States for many years and in several countries around the world, the PA role is

being integrated into health care systems. In Canada, PAs are employed by the Canadian Forces to deliver health care services to its members and in Manitoba; PAs have been working as clinical assistants since 2002.

PAs must work under the supervision of a registered physician and all PA activity takes place within the phys-ician-patient relationship. PAs support physicians in a variety of health care settings. The specific duties of a PA will vary according to individual PA competencies, the physician’s area of practice, and the work the physician chooses to assign, but may include:• Conducting patient interviews and taking medical

histories• Performing physical examinations• Counselling on preventative health care• Performing certain controlled acts delegated by the

physician

PAs are not regulated under the Regulated Health Pro-fessionals Act (RHPA), and, as such, do not have author-ity to perform controlled acts. Under appropriate circum-stances, however, a physician can delegate the authority to perform a controlled act to a PA.

DelegationAny controlled act assigned to the PA must be delegated by the physician either through a direct order (verbal or

The Ontario Physician Assistant Initiative

T


written) or through the use of a medical directive. When a physician delegates to a PA, they must do so in accord-ance with practice expectations identified in the College of Physicians and Surgeons of Ontario (CPSO) policy Delegation of Controlled Act Procedures 2007. The link to the policy is: http://www.cpso.on.ca/policies/policies/default.aspx?ID=1554

Therefore, although PAs are not authorized to in-dependently prescribe medication, a PA acting under the authority of a physician, may implement the physician’s order. The supervising physician is responsible for the quality of care that the PA provides to patients.

FAQsQHow does a pharmacist know that a PA has been

given authority to implement a physician’s order?Any prescription in a medical directive implemented by a PA must identify the:• Name and number of the medical directive• Name and contact information of authorizing phys-

ician, and• Name, designation, signature and contact informa-

tion of the PA implementing the directive.

A consistent format including all of the above infor-mation readily signifies to pharmacists that they have a proper order, permitting them to dispense the pre-scribed medication in accordance with legislative and regulatory requirements.

Q Whom should the pharmacist contact for clarification/confirmation about information on

the prescription? If there are any questions about the prescription, the pharmacist should contact the PA. If the questions cannot be resolved, the physician should be contacted for further clarification.

QWho is recorded as the prescriber on the prescription for the pharmacist’s patient records?

The physician is recorded as the prescriber on all pharmacists’ patient records. The pharmacist should

document any communication with PA or physician on the permanent pharmacist patient record.

Q What should I do if I have more questions?

More information about the use of medical directives and delegation by pharmacists can be found in the July/August 2007 issue of Pharmacy Connection.

For professional practice advice to pharmacists relating

to the PA Initiative, please contact Professional Practice,

Ontario College of Pharmacists, at (416) 847-8293 or

email [email protected].

Information about the PA initiative, including the

different demonstration projects underway, please visit

www.healthforceontario.ca (key word PA).

physician assistant

Health Canada, responsible for administering the

Controlled Drugs and Substances Act, does not

allow medical directives to be used for narcotic

or controlled drugs. To provide any narcotic

or controlled drug, a patient-specific order

authorized by a prescriber is required.

The intent of this legislation is to ensure that

a physician assesses the patient’s situation to

determine if the prescription is appropriate,

and to ensure that the physician authorizes the

prescription. Since a medical directive is used for

a group of patients and its use does not involve a

physician’s assessment of the appropriateness of

the medication for the specific patient, it does not

fulfill the federal legislative requirement.

The College is collaborating with other

regulatory colleges to inform government of

practice issues arising from the federal legislation

and to promote consistent messages among

health care professions.

Medical Directives Are Not Allowed for Narcotic and Controlled Drugs


field perspective

Documentation of DialogueA Q U I C K R E V I E W

Nadia Sutcliffe, BScPhm, RPhInspector

ne of the roles we have, as inspectors, is to ensure that pharmacists are adhering to our profession’s standards of practice. One of the standards which we assess dur-ing our inspections is documentation of dialogue. It is

required that the pharmacist communicate with and educate patients to provide optimal care and promote optimal health. Reasonable steps must be taken to enter into dialogue with the patient, or the patient’s agent, on all initial prescriptions in a community pharmacy setting. The follow-ing operational component specifies what must be documented about this interaction:

4.3.1 The pharmacist documents the dialogue in a readily retriev-

able format, including the date the dialogue occurred, with whom,

and the identity of the pharmacist.

There seems to be some confusion about what needs to be recorded as part of the documentation record. The pharmacist should document whether or not dialogue has occurred, and if it did not occur, the reason.

O


This cannot be documented by any pharmacy staff other than the pharmacist. The identity of the person counseled must be recorded, be it the patient or an agent. If it is an agent, the pharmacist must take reasonable steps to determine who the agent is or what their relationship to the patient is and to include this as part of the record of dialogue. The identity of the pharmacist providing the dialogue must also be noted as part of the record. Since dialogue is a separate action from checking/dispensing a prescription, the pharmacist must then sign separately for the dialogue. So, the pharmacist would sign for the dispensing of the drug, and then a second signature must accompany the dialogue record to clearly identify who engaged in that communication. This is required even if the same pharmacist both dispensed and dialogued the same prescription.

What is also important to document is if there were any particular concerns or questions raised during the dialogue. These could include potential drug interactions and how they should be handled, possible allergies to the medication, or any special instructions given about how to properly take the medication. The more information that is documented, the better the patient record will be. Do you have to document everything that you said dur-ing the interaction? No, but anything which was out of the norm would be advisable.

Where should the documentation of dialogue be stored? This is up to the pharmacy manager or the indi-vidual pharmacist. The College does not dictate in what manner the documentation should occur. Therefore, the

pharmacist can document on the hard copy, the original prescription, the computerized patient record, or in any other format which would be easily retrievable and read-able by an inspector. It is best to use one method of docu-mentation within the pharmacy, simply for consistency.To summarize, the following is required for proper documentation of dialogue:• the date of the dialogue • the identity of the person with whom the dialogue

took place,• if it was an agent, who it was specifically and/or their

relationship to the patient,• the identity of the pharmacist,• any significant information, instructions, or inter-

actions which were discussed during the dialogue,• if there was no dialogue, the specific reason why.

Documentation of the pharmacist’s interaction with the patient or agent is an essential part of a pharmacist’s prac-tice and an important standard of practice. It records the pharmacist’s interaction with the patient or agent. Dia-logue helps to reinforce safe and appropriate use of medi-cation. If this interaction is not recorded, it is as though it never occurred. As professionals, it is important for pharmacists to document their activities and interventions with patients. If pharmacy is to advance and gain more respect as a health care profession, pharmacists must con-tinue to actively participate in providing the best patient care possible, and documenting their actions as proof of our contribution to the health care team.

field perspective


The World Health Organization defines elder abuse as “single or repeated acts, or lack of appro-

priate action, occurring within a rela-tionship where there is an expectation of trust, which causes harm or distress to an older person”. There are many different types of abuse that can be perpetrated by many different individ-uals in a senior’s life. Elder abuse is far more common than we would like to believe. It is a serious and growing prob-lem. Ontario is home to 1.5 million sen-iors, and research indicates that current-ly four to ten per cent (60,000-150,000) of them have experienced or are experi-encing abuse of some kind. Elder abuse has no boundaries – it can happen any-where to anyone, anywhere, regard-less of socioeconomic status, ethnicity, or religion. It has been estimated that four out of five cases of elder abuse are not reported. All individuals deserve to be safe, to live with dignity, and to be treated with respect.There are five main types of abuse:• financial• neglect (intentional or unintentional)• physical• sexual• psychological/emotional

Pharmacists are well placed and have the opportunity to identify sen-iors who may be at risk, and to inter-act with these individuals, providing as-sistance and/or information to them. Some potential causes of concern that pharmacists may observe with elderly patients in their practices may include any the following:• Witnessing a caregiver or family

member belittling or threatening the senior.

• Observing that the senior becomes nervous or agitated when a particu-lar person is present.

• Sudden changes in payment meth-ods (eg. Not being ‘able’ to use a debit/credit card or write a cheque, not having enough cash)

• Misuse of medication; e.g., prescrip-tions not being refilled, increases in refill requests, refusing needed medications.

• The senior showing signs of de-hydration, malnutrition, poor hy-giene, or dressing inappropriately for the weather, possibly to hide signs of physical abuse.

• Delivery driver observing unsafe liv-ing conditions at the senior’s resi-dence, e.g., deteriorating premises, lack of heat, filth.

Be aware that seniors may have bar-riers to disclosing abuse (shame, fear, guilt) all the more if they are immigrants (language barrier, isolation, privacy issues). Pharmacists, meanwhile, may be at a loss to deal with suspected sen-ior abuse, citing lack of knowledge or re-sources as reasons for not intervening.

The provincial government has formed and is funding the Ontario Net-work for the Prevention of Elder Abuse (ONPEA). It is a non-profit charit-able organization dedicated to raising awareness about the abuse and neg-lect of older adults. There are excellent training and reference materials avail-able on the ONPEA website, (www.onpea.org) Videos, computer-animated

sessions, and downloadable electronic publications are free for use and shar-ing. Also listed on the website are useful links to regional resources, workshops, and special events.

Have a staff meeting, and start to educate and empower your employees to be aware of behaviours that are sus-pect and to keep you informed. Advo-cate on behalf of seniors!

The Ontario Network for the Pre-vention of Elder Abuse is having a na-tional conference in Toronto on Nov-ember 3-4th, 2009. Details and regis-tration information are available on their website.

A 24-hour toll-free telephone num-ber has been set up for seniors to use: 1-866-299-1011.

There are six Regional Elder Abuse Consultants across Ontario. These consultants support and strength-en partnerships between community groups, the justice system and com-munity service providers working to prevent elder abuse. They also help strengthen new and existing local in-itiatives to eliminate elder abuse, and facilitate sharing of information.

elder abuse

Guidance for Pharmacists Guidance for Pharmacists


eHealth Ontario

An update on the e-Prescribing project

The ePrescribing project, first outlined in the January issue of Pharmacy Connection, was fully launched in April with the involvement of 45 physicians,

eleven nurse practitioners and 42 pharmacies to address several objectives:• Understand the workflow impacts on physicians, nurse

practitioners, pharmacists and patients of the electronic prescribing and dispensing process, to inform the design, implementation, and change management requirements of a province-wide ePrescribing and Drug Information System.

• Reduce the number of adverse drug events by eliminating illegible paper prescriptions. (According to the Ministry of Health and Long-Term Care, there will be about 340,000 preventable adverse drug reactions in Ontario this year, resulting in 240,000 physician office visits, 36,000 hospi-talizations and 4,000 deaths.)

• Help physicians, nurse practitioners and pharmacists share information and ensure that clients are filling their pre-scriptions as instructed.

• Make it easier to identify the physician or nurse practition-er who initiated the prescription, for consultation purposes and to verify the prescription’s authenticity.

How ePrescribing worksThose health professionals participating in the project are among the very first in Canada to go ‘paperless’ through-out the prescribing and dispensing process.

Two primary care practices advanced in the use of the Electronic Medical Records (EMRs) – the Group Health Centre (www.ghc.on.ca) in Sault Ste. Marie and the

Georgian Bay Family Health Team (www.gbfht.ca) in the Collingwood area – were selected to participate in the project.

After logging into their system, reviewing a patient’s electronic record and deciding what medication to pre-scribe, physicians and nurse practitioners use their EMR to generate (write) a prescription. The system will alert the physician if the patient is taking another drug and there is a risk of an adverse interaction.

Normally, physicians and nurse practitioners who use EMRs print prescriptions, sign them, and give them to pa-tients. But physicians and nurse practitioners participating in the demonstration project can now electronically author-ize (sign) prescriptions, either by entering a second pass-word or pressing a key to ‘finalize’ the ePrescription. They then ‘assign’ the ePrescription to the pharmacy directed by the patient.

Pharmacists use a secure web application to review pending ePrescriptions. When a pharmacist is ready to fill an ePrescription, he or she ‘accepts’ the ePrescription. The pharmacist is able to see the pending prescription, as well as any allergies and adverse drug effects noted in the EMR, the current medication list, a chronological medication his-tory and a collection of relevant lab results and drug levels.

Both systems make it easier to identify the physician or nurse practitioner that created the ePrescription and to verify that the ePrescription has been authorized and is authentic.

Moreover, both systems support secure messaging with-in the EMR between physicians, nurse practitioners and pharmacists, increasing collaboration and allowing providers

The colleges of pharmacy, medicine and nursing are working with

eHealth Ontario to enable two demonstration projects in the province, one in

Sault Ste. Marie and the other in Collingwood.


to better manage workflow. Once the pharmacist dispenses the prescription, the

physician or nurse practitioner is able to check whether it has been filled.

Although many physicians already use EMR-generated prescriptions, the critical difference in this project is that this authorization can occur because it takes place within a closed system with defined participants, and with safeguards. This means of prescribing offers enhanced security for the pre-scriptions of controlled substances over a handwritten pre-scription. Each prescription has an attached serial number and an accurate record of this prescription is automatically entered on the chart. There is no opportunity for a patient to attempt modifying or forging a prescription.

From a pharmacist’s perspectiveGlenn Thompson, a pharmacist who works with the phys-icians in the Georgian Bay pilot site, says the electronic pre-scription’s legibility prevents dispensing errors, and saves time. “ePrescribing gives the pharmacist a chance to receive the prescription in advance of the patient arriving at the phar-macy,” says Glenn. “This helps the workflow since the phar-macist can have problems addressed and the medication ready before the patient arrives, and allows pharmacists more time to counsel patients on their medications. “

“Normally we’ve had to go through many channels to communicate with a prescriber, which can take some time. And, our patients often present the prescription after a pre-scriber’s office hours. If there are any prescribing issues that need clarification, or any possibility of drug interactions, it’s usually the next day before we can successfully reach the prescriber to consult with them. With ePrescribing, I just need to message the prescriber directly into the patient’s

EMR,” says Glenn. “The prescriber is alerted to the presence of a message while he or she is still at the computer with the patient freshly in mind. I don’t have to phone the reception-ist or nurse and wait for her to get the physician’s attention or wait for a fax to be read and answered. This saves time and benefits our patients”.

Patient’s show supportThe patients of both sites were told how the project would work, what information would be shared with pharmacists, and asked if they would be interested in participating. It was an opportunity at which most of them jumped. “Patients really embraced this new form of prescribing, with many asking why we hadn’t started this years ago,” said Dr. Ed-ward Hirvi, a physician in the Group Health Centre in Sault Ste Marie.

What’s Next?eHealth Ontario will study how this ePrescribing project changed the workflow for the clinicians involved. Both eHealth Ontario and the colleges will evaluate the project to determine whether new regulations, standards or guide-lines will be necessary to support ePrescribing.

The lessons learned will then inform the future prov-ince-wide Drug Information System (DIS). Expected to be in place by 2011, the DIS will be connected to pharmacies throughout the province, enabling physicians, nurse practi-tioners, pharmacists and other health care professionals to begin ePrescribing.

The provincial system will provide prescribers and dispen-sers with access to comprehensive medication profiles for all Ontarians, as well as tools that check for allergy, drug-to-drug interactions and the accurate dosing of medications.

• Electronic prescribing automates three key stages of

the prescription process: the generation, authorization

and transmission of dispensing directions for a drug or

mixture of drugs.

• All three stages must be electronic before a prescription

can be considered an electronic prescription.

WHAT IS ELECTRONIC PRESCRIBING?• An electronic prescription is not the same as a

prescription that is generated using an Electronic

Medical Record, printed, signed and then

physically transported or faxed to a pharmacy or

a written prescription that is signed, scanned and

then electronically transmitted to a pharmacy.


spt Q&A

QMay I split my internship training between two different sites?

Ideally, an SPT rotation is completed at one site with one preceptor, which ensures continuity of training and as-sessment. Since your preceptor is responsible for assess-ing the development of your competency throughout the rotation, it is necessary for you to practise predominant-ly with your preceptor. In fact, you must spend a min-imum of 18 hours per week training with your preceptor. Furthermore, doing your entire training in one site will allow you to develop more meaningful patient care re-lationships. This is especially relevant when it comes to completing patient care assignments and performing fol-low-up monitoring.

In some cases, and only with the approval of a regis-tration advisor, it may be possible to train at two differ-ent sites. SPT rotations at two different sites have been allowed in various cases, such as• when the preceptor works at two pharmacies with re-

markably different types of patients• when the majority of hours are spent at a community

pharmacy, with some hours spent at a pharmacy with a specialized type of practice

• when a hospital practice site is combined with the out-patient pharmacy in that hospital, and

• when two pharmacies within the same organization serve significantly different patient populations or pre-scription volumes.

In all of these cases, the request had to be approved by a Registration Advisor and both training sites had to be reported.

Before allowing you to divide your SPT rotation

between two sites, the registration advisor will consid-er a number of factors. The second pharmacist must be a member in good standing, meaning that there are no terms, conditions, or limitations on his or her certificate of registration; he or she must not have any current allega-tions of professional misconduct, incompetence, or incapa-city; and he or she must never have been found guilty of professional misconduct, incompetency or incapacity. He or she must be willing to supervise you and to communi-cate regularly with your preceptor about the progress of your training. While the second pharmacist does not have to meet the training requirements that a preceptor does, he or she should be familiar with the NAPRA Entry-to-Practice Competencies for Pharmacists, in order to give appropriate feedback on your progress to your preceptor.

In reviewing your request, the registration advisor will also consider whether the second site meets the SPT Practice Site criteria. For example, the second site must provide direct patient care in Ontario, must not current-ly be in disciplinary proceedings or have had disciplinary findings against it within the past six years, must not have any unsatisfied (i.e., unresolved) accreditation issues, and must not have a conflict of interest with you. This will ensure that the site provides you with an appropriate en-vironment and a good learning opportunity.

Approval for dividing an SPT rotation between two sites is given on a case-by-case basis, to ensure that you will have appropriate opportunities to demonstrate all of the NAPRA Entry-to-Practice competencies for phar-macists. To initiate the approval process, you will need to propose your case in writing to a registration advisor for consideration.

Diana Spizzirri, R.Ph., B.Sc.Phm., M.Ed.Penny Tsang, R.Ph., B.Sc.Phm.Deanna S. Yee, R.Ph., B.Sc.Phm., M.Sc. Registration Advisors


For complete information & electronic mailing of the Health Canada Advisories/Warnings/Notices subscribe online at: http://www.hc-sc.gc.ca/dhp-mps/medeff/index_e.html

MedEffect e-Notice is the new name which replaces Health Canada’s Health_Prod_Info mailing list. The content of the e-notices you receive will remain the same and are now part of MedEffect, a new Health Canada Web site dedicated to adverse reaction information. MedEffect can be visited at www.hc-sc.gc.ca/dhp-mps/medeff/index_e.html

Health Canada Notices are also linked under “Notices” on the OCP website: www.ocpinfo.com

health canada advisories & notices

August 19, 2009

August 14, 2009

August 7, 2009

August 5, 2009

July 31, 2009

July 27, 2009

July 23, 2009

July 10, 2009

July 9, 2009

July 6, 2009

June 29, 2009

June 26, 2009

June 25, 2009

June 24, 2009

June 22, 2009

June 19, 2009

June 18, 2009

June 17, 2009

Health Canada is advising consumers not to use the following 30 foreign health products due to concerns about possible side-effects - all skincare products manufactured by Clarcon Biological, Chemistry Laboratory Inc. (9 products), Delima Raja Urat, Cao Gen Bai Lin Wan, Whey liquid products (18 Products) and Stamina-Rx.

Health Canada is informing health care professionals and Canadians that it is conducting a safety review of the potential association between the asthma drug Xolair (omalizumab) and an increased risk of cardiovascular problems.

Notice to Hospitals: Medtronic is recalling Medtronic Paradigm Quick-set Infusion Sets ((Models MMT-396, MMT-397, MMT-398 and MMT-399) that have lot numbers starting with the number “8”. These Quick-set infusion sets are used with MiniMed Paradigm insulin pumps. Use of the affected lots can result in too much or too little insulin being delivered.

Authorized over-the-counter oral sodium phosphate products have been relabeled to remove the purgative indication and are now available for sale.

Health Canada is advising consumers not to use 3 foreign health products due to concerns about possible side-effects: Air Ikan Haruan, Neovidan and XP Tongkat Ali Supreme. The Singapore Health Sciences Authority (HSA) warned consumers to not buy or use Air Ikan Haruan after it was found to contain undeclared dexamethasone. The Hong Kong Department of Health warned consumers not to buy or use the product Neovidan after it was found to contain undeclared prednisolone and mefenamic acid. The Singapore Health Sciences Authority (HSA) warned consumers to not buy or use XP Tongkat Ali Supreme after it was found to contain undeclared tadalafil.

Health Canada is warning Canadians with milk allergies not to use the unauthorized health product, Dophilus Chewable Tablets (90 tablets), labelled as “non-dairy,” because they contain trace amounts of milk protein from dairy ingredients used in the production process.

Further to scientific study results presented at a conference, GlaxoSmithKline is notifying healthcare professionals of new safety information regarding a potential association of myocardial infarction in patients treated with TELZIR (fosamprenavir).

Health Canada is warning consumers not to use the unauthorized health product labelled as Specific-Formula Arthro-Ace as it was found to contain undeclared dexamethasone and may cause serious health effects. Specific Formula Arthro-Ace is being promoted as a natural health product for the relief of arthritic pain.

Health Canada is informing Canadians of an ongoing safety review of the potential association between the diabetes drug Lantus (insulin glargine) and an increased risk of developing cancer.

Health Canada is warning consumers not to buy or use the unauthorized health product Hardcore Energize Bullet liquid energy drink as it has been reported to Health Canada that a vial of this product was subject to tampering.

Health Canada is advising consumers not to use the following 11 foreign health products due to concerns about possible side-effects – Slimbionic, Xsvelten, Herbal Xenicol, BioEmagrecim (FDA update), 999 Fitness Essence, Libimax, 24” ince, Light Some, Paiyouji, Pearl White Slimming and Reducing Weight Easily.

All lots of the prescription drug PMS- Phenobarbital tablets in the 60 milligram (mg) format (DIN 00178810) are being recalled because some oversized tablets were recently found on the Canadian market. The oversized tablets were found to contain more Phenobarbital than the label indicates, exposing patients to the potential risk of accidental overdose.

Health Canada has conducted a safety review and concluded that piroxicam should no longer be used to treat short-term pain and inflammation due to an increased risk of serious skin reactions and gastrointestinal problems relative to other similar drugs.

Consumers should not use the unauthorized product Nutural Slim, which is promoted as a weight-loss product, as it was found to contain the undeclared pharmaceutical ingredient sibutramine and also an undeclared pharmaceutical ingredient similar to sibutramine.

Clean Testing HIV Home Test Kit, or any HIV home test kits are not to be used, as these are unlicensed medical devices and may provide false test results.

The FDA warned consumers not to buy or use three lots of Levemir insulin vials (lot numbers XZF0036, XZF0037, and XZF0038). These lots, which were reported stolen in the U.S., have reappeared for sale on the U.S. market.

Do not use 3 foreign health products due to concerns about possible side-effects: Zicam Cold Remedy Nasal Gel (15mL, NDC 62750-003-10) Zicam Cold Remedy Swabs (20 swabs, NDC 67250-003-20) and Zicam Cold Remedy Swabs, Kids Size (20 swabs, NDC67250-003-21)

EMD Serono Canada Inc. has in consultation with Health Canada, withdrawn the marketing authorization of Raptiva in Canada due to safety concerns.


registration Q&A

Chris Schillemore, R.Ph., B.Sc.Phm. M.Ed.Manager, Registration Programs

Q I know the Pharmacy Examining Board charges a fee for the Qualifying Exam. What are the

additional fees I will have to pay before I can become registered as a pharmacy technician with the College?Later this fall, OCP will pilot the remaining activities asso-ciated with the entry-to-practice requirements: the Phar-macy Technician Jurisprudence Exam and the Structured Practical Training Program (for CCAPP graduates) or the Structured Practical Evaluation (for technicians complet-ing the Bridging Program).

Note that the fees associated with these activities will be reviewed and finalized this fall. Below you will find a list of the anticipated fees. We will post the fee structure on our website as soon as it is available.

Q I am currently a registered pharmacy technician in Alberta, working towards becoming regulated,

and will be moving to Ontario in the fall. How should I proceed to become registered in Ontario? There is a difference between being on a register and being a regulated health professional. At present, there are no regulated pharmacy technicians in Canada, but we expect that Ontario will pass the enabling legislation which will enable the regulation of pharmacy technicians by late 2009 or early 2010.

Alberta maintains a voluntary register or list of phar-macy technicians, just as Ontario maintains a list of phar-macy technicians who have completed the OCP volun-tary certification exam. Once the legislation passes, only someone who has met the entry-to-practice requirements

Filing fee: Required to open a file with OCP, prior to registering for the

Jurisprudence Exam (Note that this fee will not apply to individuals who have

already been certified by OCP.)

OCP Jurisprudence Exam: A multiple-choice examination to test your

knowledge and understanding of the laws concerning the production,

distribution, advertising, sale, and use of drugs in Ontario. To be held in Toronto;

anticipated in October.

Structured Practical Training (for CCAPP graduates): A supervised

competency-based training period that includes regular assessment. Training

sites and preceptors will need to be established and approved by OCP.

Structured Practical Evaluation (for technicians required to complete the

Bridging Program): Evaluation of the “independent double check,” following

completion of the Drug Distribution course, will take place in the individual’s

workplace.

Application for Certificate of Registration, once all registration

requirements have been met.

Annual fee: (Due March 10th each year) For the first year, if paid on or after

September 1st. Council has agreed in principle that these fees will be two thirds

of a pharmacist’s fee.

bulletin board

Canadian Patient Safety Week (CPSW) is November 2 – 6 with a theme focused on communication – Ask. Listen. Talk. Register now and help increase awareness of patient safety issues across Canada! For more information, visit www.patientsafetyinstitute.ca Questions? Email [email protected]

7T9 Pharmacy 30 Year Reunion - October 2, 3 & 4, 2009, Blue Mountain ResortPlease contact Karen (Zellen) Vanderlee at [email protected] Joanne (Hodgins) Duff at [email protected] to be added to the contact list


and is registered with OCP may use the title of Pharmacy Technician. Those who are not regulated may call them-selves pharmacy assistants. To become a regulated phar-macy technician in Ontario, you will need to follow the registration process outlined on page 8.

While Ontario will start regulating pharmacy techni-cians by early 2010, other provinces intending to regulate pharmacy technicians are at various stages of the process. It is the intention of NAPRA and all the provinces to have a national model of licensing pharmacy technicians simi-lar to that of pharmacists. To that end, there is a national accreditation process developed for pharmacy technician programs and the Pharmacy Examining Board of Canada (PEBC) is developing a national entry-to-practice exam-ination for technicians to be piloted in late August 2009.

While it is too early to discuss the details of labour mobility, we expect that in the future, among provinces that have regulated pharmacy technicians in place with a similar scope of practice, the provisions of labour mobil-ity legislation will apply.

Q I am an international pharmacy graduate, but my credentials do not qualify me to become

a pharmacist here. Is there any way that my diploma can help me become a regulated pharmacy technician? What steps do I have to take to become eligible to register?We anticipated the need for a mechanism for internation-ally educated pharmacists or pharmacy technicians to become regulated pharmacy technicians in Ontario. At present, international pharmacy graduates working as pharmacy technicians or assistants in Ontario have the choice of proceeding as an “in the profession” applicant. They need to complete the PEBC Evaluating and Quali-fying Exams and the bridging education that is currently being offered. However, bridging education for techni-cians presently working in the profession will eventually be phased out. There will be a need for a permanent inter-national pharmacy technician bridging program, just as there is for a bridging program for internationally educated pharmacists. Centennial College is currently working on such a program, and more information will be provided in an upcoming issue of Pharmacy Connection.


The Asthma Society of Canada (ASC) is a nation-ally registered, voluntary health organization with a 32-year reputation of providing health education

services to consumers and health care professionals. The Society offers evidence-based and age-appropriate asthma and allergy education, and disease management programs. The Asthma Society is dedicated to empowering every child and adult with asthma in Canada to live an active and symptom-free life.

Recently, the ASC has implemented the Partnership in Lung Age Testing and Education (PLATE) initiative supported by the Public Health Agency of Canada. The PLATE Programme is a demonstration project designed to examine the effectiveness of a population-based approach to the management of asthma, associ-ated allergies and COPD. Community-based “Airways Clinics” were organized in various community settings namely pharmacies, malls, libraries, Community Cen-tres in two cities (Toronto and Hamilton) and offered screening spirometry testing and respiratory education

PLATE initiative

Partnership in Lung Age Testing and Education (PLATE) Programme

to community residents and the general public. Within the PLATE initiative, the ASC is outreaching

to pharmacists practicing in Ontario and would like to inform them about the ASC services and educational materials. The ASC offers a variety of printed educa-tional materials including the Asthma Control Booklet Series that can be ordered free of charge. Clients with asthma and associated allergies can be also referred to speak to a Certif ied Asthma Educator by contacting the Asthma Info Line by phone at 1-866-787-4050 or e-mail at [email protected]. As well, they can learn more about asthma and allergies by visiting the ASC websites (www.asthma.ca; www.asthmameds.ca and www.fourseason-sofasthma.ca). Additionally, the ASC offers age-appro-priate asthma education to kids (www.asthmakids.ca) and teenagers (www.airsquare.ca) with asthma. More-over, people with asthma can share their experiences and participate in advocacy initiatives towards better asthma care by joining National Asthma Patient Alli-ance (NAPA).

A S T H M A S O C I E T Y O F C A N A D A


update on technology

Staff at the College continue to review existing processes and evaluate opportunities to improve and refine the way we

manage our everyday work in support of our mandate and objectives. Two recent milestones are:

Launch of online votingThe new BigPulse platform allows for easy access to the voting process, with the click of a mouse. No paper, no

postage, no delays – just efficient, user-friendly, accurate and efficient voting and tabulation of results. This will save

the College considerable costs and time in managing the elections process each year.

Here’s what members had to say about their recent

online voting experience:

• Being able to vote online definitely encourages participation !

• I suggest that you keep reminding members on a regular basis.

With no paper lying on the desk to remind a member, they will

need help to be sure and vote electronically on time. I think this is

a good idea!

• I am not fond of using the internet vs paper but this was painless.

• Outstanding voting process. Congratulations to who ever put this

together. Probably costs the College less money to run an election

in the long run.

• Excellent, efficient and enviromently friendly voting procedure

• Being able to vote online definitely encourages participation !

• It is very easy and convenient to vote online. Thank you.

Online version of Pharmacy Connection(first edition to be launched with November issue)

In the recent survey of members’ perceptions and opinions of Pharmacy Connection, we found that many still prefer to

receive the print product. However, over time, a staggering 25% of members have opted out of receiving a mailed print

copy, preferring to read the journal online – many stating support for the environment as their reason for doing so.

Another comment we heard from members responding to the survey, was that they wanted to see short synopsis-type

summaries of articles wherever possible. Considering these two preferences, we will launch an electronic “bulletin”

that will be communicated through an email (with link to bulletin) to all members at the time that the print product is

being mailed – effective with the next (November) issue of Pharmacy Connection.

This new online feature will offer members these benefits:

• Provide the highlights of articles – a sample of what readers can expect

• Provide a top line summary that will alert the online virtual readers that the new issue is posted on the website

• Introduce a new communications platform to build on, as we move more and more professional news and articles

online for members to access anywhere, anytime.


This article is intended to help designated managers who need to prepare an action plan addressing issues identified by the College’s inspector during

an inspection.

1. What is an action plan?Most inspection reports identify some practice or regula-tory issues that need to be improved or brought into com-pliance. An action plan is a pharmacy’s written assurance that the issues identified during the inspection have been fully addressed. It must explain in detail what steps have been taken to resolve each of the issues.

2. Who is responsible for submitting the action plan? The designated manager is ultimately responsible for all actions at the practice site, and the designated manager or their delegate’s signature on the action plan confirms that all the issues have been addressed.

3. Where do I send my action plan?Action plans should not be sent directly to the inspector.

inspectors’ corner

Action PlansAction PlansAction PlansRose Fitzgerald, B.Sc.Phm., Inspector


They should be submitted to the administrative assist-ant for the Professional Practice Department by mail or by fax (416 847-8292), or scanned and attached to an e-mail.

4. What happens to the action plan once it is received at the College?Currently, the action plan is matched with the inspec-tion reports and given to the appropriate inspector. The inspector will determine if the action plan is com-plete. A complete action plan will be scanned and attached to the pharmacy file. If it is found to be in-complete, a note will be attached to the report and re-turned to the administrative assistant, who will then contact the designated manager.

5. What are the most common problems found in sub-mitted action plans? Action plans document the processes or activities undertaken by the designated manager to resolve the identified issues. They must be complete and detailed. The following are some of the problems inspectors have encountered in action plans:• receipts not supplied for texts• no response to an issue • insufficient responses such as “all done” or a check

mark by each of the issues listed• vague responses to issues• action plan not signed by the designated manager.• illegibility (it is preferable for action plans not to be

handwritten)

6. What are some of the common issues identified during inspections, and how should these be ad-dressed in the action plan? a) Maintenance of the pharmacy (both front store and

dispensary, including walls, f loors, and ceilings) - de-scribe the cleaning schedule for the pharmacy - sup-ply photos of improvements made.

b) Missing library texts - provide copies of receipts (or back-order notices) for purchased texts.

c) Outdated drugs/products found in the dispensary and front store - describe the system you will be using to identify drugs/products with upcoming ex-piry dates.

d) Insufficient documentation of dialogue for prescrip-tion drugs. The DM should detail how he/she will fol-low up to ensure that documentation improves.

e) Professional image of pharmacy and staff - the DM should review this issue with the pharmacist(s) in question. In many cases, it may be helpful to have each pharmacist submit an individual response to the issue.

7. I am the DM but was not on duty during the in-spection, and I’m unclear on some of the issues that were identified. It is not always possible for the inspection to take place when the DM is on duty. It would be helpful if you could leave a message for the inspector indicating what day(s) of the week you are available - we will do our best to accommodate you. As well, if you have a vaca-tion planned, let your inspector know when you will be absent. Contact your inspector by telephone or e-mail to re-view your report.

8. What should I do if my action plan is due but I am waiting for some texts to arrive?Send in your action plan and indicate that receipts will follow.

9. Why does my inspection report state that there will be another inspection (i.e., a re-inspection)? Either the designated manager or the pharmacist on duty will be told at the end of an inspection whether a re-inspection is required. A re-inspection is not a pun-ishment or a penalty; it is a follow-up to confirm that the pharmacy has addressed issues that were identified. Although the re-inspection is typically more focused than the routine inspection, any additional issues iden-tified during the re-inspection will be added to the re-inspection report.

Re-inspections typically occur within one year of the initial inspection. Most re-inspections are concluded with or without an action plan.

In many cases, it may be beneficial to have a phar-macy staff meeting and get input from your staff on ways to address the issues identified. Ask your inspect-or what they have seen that works in other pharmacies to help improve systems and procedures.


FIRST NAME LAST NAME OCP No.

Dalia Abdalla 608737Leilani Banaag 605383Andrew Black 605617Natalie Borden 206672Sarah Boudreau 603613Helen Cabiao 606209Roger Campbell 17728Doris Cheung 200356Marie Ivie Dequito 606224John Ellis 9660Monaliza Esguerra 212897Denise Fox 203228Irving Goldberg 12971Irwin Goldkind 13064Marcus Green 13412Anthony Gregson 13544Daniel Harris 14249Christopher Healy 604001Meghan Highley 609831Michele Holowachuk 101451Margaret Kehoe 98906Robert Koval 18961Krikor Kradjian 107700

FIRST NAME LAST NAME OCP No.

Kathleen Lawday 85375Yolaine Madge 91766Marie-Helene Maheu 609326Gregory Melville 215133Albert Moughalian 206920Duc Nguyen 102407Lloyd Pihulak 214381Alison Pilla 78301Robert Richardson 33782Gilbert Rose 42714Robert Rosenberg 50881Jeanette Santiago 605390Geoffrey Seymour 43648Ashit Shihora 109452Kelli Smith 607198Tuan Tran 201864Joseph Wdowiak 42277Suzanne Williams 607020Jackie Yeung 109886Garland Young 101060Antoine Zada 45365Barrie Zemmel 50024

Members suspended for non-payment

practice Q&A

Shakti SawhPractice Advisory Officer

Q Do pharmacists have to provide their name and license number when requested by patients?

All members of OCP have a professional and moral obli-gation in return for the trust given to them by society. They are obliged to act in the best interest of, and advo-cate for the patient, to observe the law and to practice in accordance with ethical principles and their respective Standards of Practice.

As an Ontario pharmacist in good standing, your phar-macist follows:• All legal requirements necessary to operate as an On-

tario health professional, including professional conduct rules, patient care, and confidentiality

• The Standards of Practice as set by the Ontario Col-lege of Pharmacists

• The Code of Ethics as set by the Ontario College of Pharmacists

• All legal requirements for practicing in and/or operat-ing a pharmacy.

Best practices would suggest that if a patient requested the name and license number of a pharmacist for their re-cords, this information should be provided. This will al-low the patient to contact the same pharmacist in future to facilitate the continuity of care. The name and license number of a pharmacist is also accessible by conducting a pharmacy search using the web link https://members.ocpinfo.com/ocpsearch/


Case 1

Failure to counsel; labelling error

Member: Samia Botros

Pharmacy: Main Drug Mart, Toronto

Hearing Date: June 23, 2009

Facts This case proceeded by way of Agreed Statement of Facts and Joint Submission on Penalty.

The College received a complaint from a patient who had been diag-nosed with rheumatoid arthritis and who had received a prescription for three drugs, including methotrex-ate 15mg to be taken orally once a week. The patient had the prescrip-tions filled by Ms. Botros. The pa-tient began taking the methotrexate the following day, in a daily quantity of six tablets, which was the quantity she believed, from the pharmacy label directions, she was supposed to take. Over the next two days, having taken 12 methotrexate tablets, the patient felt increasingly ill. She contacted the pharmacy, and was told by the phar-macist on duty that it could be a side effect from a drug she was taking.

The patient continued to take six methotrexate tablets each day, and her condition deteriorated. She even-tually stopped taking all of her medi-cations and made an appointment to see her physician, who discovered the error. The physician had prescribed six methotrexate tablets to be taken once per week, but the patient had taken six tablets per day for eight days. In the following two weeks, the patient was twice admitted to hospital on an emergency basis. Her ingestion of methotrexate likely contributed to

the medical conditions for which she was hospitalized.

The intent of the original pre-scription was for the patient to take six methotrexate 2.5mg tablets by mouth once each week to achieve a full weekly dose of 15mg. The Mem-ber filled the prescription by dispens-ing 100 methotrexate 2.5mg tablets. However, she provided the following directions for use on the label: “TAKE 6 TABLETS ONCE A E.”

The patient told the College that when she picked up her prescription at the pharmacy, the Member provided her with a sealed bag containing her medications, and said only, “Have a nice day.” The patient stated that the Member did not provide any counsel-ling about any of the three medica-tions being dispensed to her. The pa-tient was not familiar with medical terminology and assumed that the dir-ections for use on the label meant that she was to take six methotrexate tab-lets each day, which she did.

When contacted by the College about the medication error, the Mem-ber’s initial response was that metho-trexate could cause stomach upset but not a heart attack. She also ex-plained that the label contained a typ-ing error and should have been six tablets per week.

If she testified, the Member would state that she wrote the words “TAKE SIX TABLETS ONCE A E” with the intention of communicating to the patient “TAKE SIX TABLETS ONCE AS EXPLAINED.” How-ever, the Member would acknowledge that she failed to document adequate or comprehensible directions for use on the prescription label. The Mem-ber would also acknowledge that “A

E” is not a recognized abbreviation in pharmacy for “as explained” or for any other phrase or words.

If she testified, the Member would also state that, in her experience, physicians who prescribed methotrex-ate often varied the dosage on a trial-and-error basis. Consequently, the Member did not want to put a specif-ic dosage on the label, on the under-standing that the dosage might be ad-justed up or down before the medi-cation was finished. However, the Member acknowledged that her pro-fessional obligation was to document the directions for use provided by the physician, and not directions for use as they might be altered in the future.

If she testified, the Member would also state that she discussed the issue of dosage of methotrexate with the patient and specifically advised her to begin with six tablets per week and to vary the dosage as instructed by her physician from time to time. The Member would state that she wrote “expl pt dsg” on the prescription hard-copy to document this conversation. The Member would further state that she also advised the patient to take the methotrexate as directed by her doctor, and that the patient may have misunderstood her physician’s direc-tions respecting the use of the drug. However, the Member acknowledged that it was her responsibility to coun-sel the patient effectively regarding proper use of the medication, which she failed to do, especially in light of the potential hazards presented by the drug in question.

If she testified, the Member would also state that the dispensing error was an isolated incident arising from the fact that the pharmacy is busy,

deciding on discipline


typically dispensing approximately 300 prescriptions each day. How-ever, the Member acknowledges that this fact does not excuse a medica-tion error.

The Panel also received evidence about other possible medication er-rors on the part of the Member.

Admission of Professional Misconduct In connection with the methotrex-ate labelling error and failure to pro-vide accurate directions for use or patient counselling, the Member pleaded guilty to failing to maintain the standards of practice of the pro-fession, contravening the Drug and Pharmacies Regulation Act and the Food and Drug Regulations, and en-gaging in conduct or performing an act relevant to the practice of phar-macy that, having regard to all the circumstances, would reasonably be regarded by members of the profes-sion as disgraceful, dishonourable or unprofessional.

Decision and Reasons The Panel noted that this was a very serious medication error and that there was patient harm. The Panel also noted that the Member’s direc-tions for use were incomprehensible and meaningless, and that the patient did not get proper counselling. The Panel felt that the Member had no recognition of the therapeutic indica-tion of this drug and how it is com-monly dispensed. Further, the Panel expressed the view that the Mem-ber’s explanations for the error were grossly inadequate and suggested that she did not understand the serious consequences of the error. The Panel

was also concerned about the Mem-ber’s prior history of medication errors and her inadequate and appalling re-sponses to those incidents. While the Panel acknowledged the Member’s cooperation throughout the investi-gation, and her guilty plea, the Panel felt that these mitigating factors did not offset the long list of aggravating factors.

The Panel reviewed the Joint Sub-mission on Penalty and prior deci-sions of the Discipline Committee. In weighing those decisions against the facts of this case, the Panel en-dorsed the Joint Submission on Penal-ty, particularly in regard to the range of coursework and the restrictions on the Member’s ability to be a Desig-nated Manager. The nature of the coursework in the Joint Submission on Penalty should prevent future dis-pensing errors. However, the Panel was concerned that the Member has not learned from her past mistakes and that she could appear before the Discipline Committee in the fu-ture. The Panel cautioned the Mem-ber that she is being given a valuable opportunity to set herself on a more constructive and proactive course of practice, provided she chooses to learn from the variety of courses she will be required to attend as part of the Discipline Committee’s Order.

Order 1. A reprimand.2. Specified terms, conditions, or lim-

itations on Ms. Botros’s Certificate of Registration:

a) requiring her to complete suc-cessfully, at her own expense, within 12 months of the date of this Order, remedial training as

follows: the Jurisprudence sem-inar offered by the College; CPS I Module 3: Basic Professional Practice Labs, and CPS II Mod-ule 3: Advanced Communica-tion Skills; and also, Law Lesson 2 (Regulation of Pharmacy Prac-tice), Law Lesson 4 (Standards of Practice), and Law Lesson 7 (Professional Liability);

b) prohibiting her from acting as a Designated Manager in any pharmacy until she has suc-cessfully completed the remed-ial training exercises specified above;

c) requiring that any Designated Manager that the Member ap-points to manage any pharmacy she owns must be acceptable to the College, based on certain criteria.

3. A suspension of Ms. Botros’s Cer-tificate of Registration for a period of two months, with one month of the suspension to be remitted on condition that the Member com-plete the remedial training exercises specified in paragraph 2a, above;

4. Costs to the College in the amount of $2,500.

Reprimand The Panel was astonished at the number of ongoing serious errors committed by the Member, and felt that she had not taken her previous errors seriously, and that past remed-ial attempts to improve her practice had not been successful. Dispensing errors are serious matters that cannot be taken lightly. The pharmacist is the final check in providing medications to patients, and must ensure thera-peutically that the right drug in the



appropriate dose is provided to the patient to treat the specific diagnosis/illness.

The Panel felt that the Member had the opportunity to catch this er-ror when the patient called to check her prescription, but chose to dismiss her health concerns without appropri-ate investigation. This cannot be tol-erated. If true pharmaceutical care protocol had been followed, this error would have been corrected immedi-ately and no harm would have come to the patient.

Part of the pharmacist’s respon-sibility is to communicate with pa-tients to ensure they fully understand the medication therapy, dosage, side effects, and appropriate usage. Addi-tionally, a pharmacist cannot arbitrar-ily create new directions for inclusion on the prescription label. In fact, none of the Panel members knew what “A E” meant. The Member’s action was, in short, deplorable.

The Panel hoped Ms. Botros had learned from this experience because it did not want to see her in front of another complaints or discipline panel again. The Panel noted that a future panel may impose even harsher penal-ties for future infractions concerning patient safety.

Case 2

Failure to comply with Order of

Discipline Committee

Member: Zhijian (Peter) Huang


FactsThis case proceeded by way of Agreed Statement of Facts and Joint

Submission on Penalty. The Mem-ber participated in the hearing via teleconference.

The sole allegation of professional misconduct related to the Member’s failure to comply with the Order of the Discipline Committee dated April 21, 2006, as amended by the Order of the Divisional Court dated September 28, 2007. The Member did not pay costs to the College, fixed at $10,000 by the Orders, within the specified time limit.

After the time limit had expired, the College agreed to a proposal by the Member’s counsel that the Mem-ber pay the costs award in four instal-ments over a period of four months. The Member did not provide post-dated cheques which he had agreed to provide by November 15, 2007. Four days later, the College received one instalment, but the cheque was subsequently returned due to insuffi-cient funds.

The Member was invited to pro-vide a submission explaining why he had not remitted payment. The Member’s counsel informed the Col-lege that the Member had been hit by a truck and was unable to work. The Member subsequently provided three prescriptions and a medical form con-firming the Member’s absence from work for a period in January 2008. The Member did not provide the Executive Committee with any ex-planation, particulars, or additional documentation respecting his med-ical condition. The Executive Com-mittee referred specified allegations of professional misconduct to the Disci-pline Committee in January 2008. In February 2008, the College received a bank draft in the amount of $10,000

from the Member for the outstand-ing costs.

If he testified, the Member would state that financial and medical prob-lems arising from his accident inter-fered with his ability to pay the costs to the College on or before the re-quired date.

Admission of Professional MisconductThe Member pleaded guilty to en-gaging in conduct that would reason-ably be regarded by members of the profession as disgraceful, dishonour-able or unprofessional, with respect to his failure to comply with a prior Or-der of the Discipline Committee.

Decision and ReasonsThe Member’s relationship with the College is at the centre of the case. Regrettably, the Member’s ongoing discipline issues indicate a flagrant disregard for the College as the gov-erning authority over pharmacists. The Member can only be described as ungovernable. This is the Mem-ber’s third appearance before the Discipline Committee and relates to his failure to abide by the terms of the original Discipline Order. The Panel was appalled that so much time and expense was being expended to com-pel the Member to recognize his obli-gations under the prior Order.

Failure to comply with an Or-der is outrageous. Every pharmacist has both a legal and professional re-sponsibility to accept the jurisdiction of the College to self-regulate and to discipline its members. If one choos-es to practise pharmacy in Ontario, one agrees to the College’s role and jurisdiction.



The Member’s disregard of the pri-or Order amounted to professional misconduct, and the Joint Submis-sion on Penalty was appropriate. The Panel strongly supported the restric-tions on the Member’s eligibility to return to the practice of pharmacy in Ontario and, in particular, the re-quirement that he attend a course in ethics for professionals.

Order1. A reprimand.2. Specified terms, conditions, or lim-

itations on Mr. Huang’s Certificate of Registration requiring that he complete successfully, at his own expense, a course in ethics for pro-fessionals that is acceptable to the Registrar of the College before re-turning to the practice of pharmacy in Ontario.

3. A suspension of Mr. Huang’s Cer-tificate of Registration for a period of one month, with the suspension to commence when the Member becomes eligible to return to the practice of pharmacy in Ontario, and to run without interruption until completed and not concur-rently with any other suspension.

4. Costs to the College in the amount of $500.

ReprimandThe Panel was appalled that this was the Member’s third appearance be-fore the Discipline Committee. The Panel was deeply disturbed and dis-appointed by his lack of respect for the regulatory body and the profes-sion, as demonstrated by his repeated disregard of previous Orders.

The Panel felt it was unaccept-able that the College had to make

allegations of professional miscon-duct against Mr. Huang a third time simply to enforce a prior Order. The Panel commented that Mr. Huang caused five professional persons to hear a case which, it appeared to the Panel, Mr. Huang believed to be frivolous. Such behaviour is dis-graceful, dishonourable, and un-professional for a member of this profession.

Case 3

Dispensing without authorization;

record keeping discrepancies

Member: Gary Chin


FactsThis case proceeded by way of Agreed Statement of Facts and Joint Submission on Penalty.

Mr. Chin was the Designated Manager of MediSystem (“the Phar-macy”) from July 1999 to February 2001, and remained a narcotic signer and dispensing pharmacist thereafter. He was a part-owner and director of the Pharmacy until it was sold in September 2007. The Pharmacy cur-rently provides pharmacy services to approximately 165 long-term care homes, which have approximately 17,318 beds.

This case concerned prescription services provided to five residents of College Gardens, a non-registered long-term residential care facility pro-viding residential facilities to a small number of individuals of varying ages with mental illness. College Gardens was owned by the same individual who owned Fairview Nursing Home,

a registered long-term care facility. MediSystem entered into an agree-ment with Fairview Nursing Home to provide pharmacy services to its resi-dents, as well as to those of College Gardens.

The College received a complaint from an Ontario physician regarding her patient D.B., a 76-year-old woman diagnosed with schizophre-nia. D.B. was a resident of College Gardens who had recently become a patient of the physician. The phys-ician was concerned that the Phar-macy had been dispensing prescrip-tion drugs, including Isotamine, for D.B. for approximately seven years without any apparent prescription authorization or ongoing monitor-ing of the patient or her use of these drugs.

In the course of investigating the complaint, it appeared to the College that there were other dispensing ir-regularities in relation to other resi-dents of College Gardens. A further investigation was therefore carried out. That investigation revealed dis-pensing irregularities concerning four additional College Gardens residents.

If he were to testify, Mr. Chin would state that he accepts full re-sponsibility for the dispensing irregu-larities concerning the five residents. He would state that when the Phar-macy’s Designated Manager inquired several times about the Pharmacy’s arrangement with College Gardens and Fairview Nursing Home, and specifically about recording the pre-scription authorizations and ensuring that the Pharmacy obtained copies of any necessary documents related to the residents, he assured her that he would ensure the Pharmacy obtained


copies of any necessary documents related to the residents of College Gardens.

If he were to testify, Mr. Chin would explain that he understood that the Pharmacy would dispense medi-cation to residents of College Gar-dens in accordance with the terms of the arrangement between the Pharmacy and both Fairview Nurs-ing Home and College Gardens. Mr. Chin would testify that he under-stood that residents of College Gar-dens would be cared for by Fairview Nursing Home’s medical director and nursing staff, and that any authorized prescriptions for residents of College Gardens would be communicated to the Pharmacy by the prescribing doc-tor, or a nurse acting as agent for that doctor, by telephone or facsimile.

If he were to testify, Mr. Chin would explain that as a result of the terms of the Pharmacy’s arrange-ment with Fairview Nursing Home and College Gardens, assurances from College Gardens staff that they would retain and deliver all necessary documents relating to the residents, and random reviews conducted by Pharmacy staff of the Pharmacy’s records to ensure the Pharmacy ob-tained copies of any necessary docu-ments related to the residents of Col-lege Gardens, he believed at all times that he and the Pharmacy were au-thorized to dispense the medications at issue.

If he were to testify, Mr. Chin would describe changes that have been made at the Pharmacy as a re-sult of these proceedings to reduce the possibility that any future discrep-ancies might arise. These changes include reconfirming authorizations

received from any rest, retirement, or group home, ensuring quarterly medi-cation reviews are conducted for all residents, flagging three-month re-view dates in the Pharmacy’s comput-er system, and developing a new digit-al pen technology to allow doctors to order and automatically transmit pre-scription orders to the Pharmacy and to electronically complete and trans-mit three-month reviews.

Admission of Professional MisconductThe Member pleaded guilty to vari-ous acts of professional misconduct which occurred while he was a dir-ector, part-owner, and a dispensing pharmacist at the Pharmacy, including dispensing drugs without prescriptions or other authorizations to various pa-tients between May 2004 and Sep-tember 2004; dispensing Isotamine to D.B.; and failing to keep records as required relating to five different pa-tients during the period May 2004 to September 2004. The Member ad-mitted that his conduct would reason-ably be regarded by members of the profession as disgraceful, dishonour-able and/or unprofessional. The Panel accepted the Member’s plea to these allegations and accepted the parties’ joint submission to withdraw the re-maining allegations.

Decision and ReasonsThe Panel was presented with an Agreed Statement of Facts for Sanc-tion, and a Joint Submission on Penal-ty. The panel was also presented with the Discipline Committee’s decision in the case of Helen Huh, who was the Designated Manager of the Pharmacy during the time in question. Ms. Huh

was found guilty of allegations of pro-fessional misconduct similar to those made against the Member, and the penalty ordered against Ms. Huh was similar to the penalty presented for Mr. Chin.

The Panel acknowledged that a Designated Manager is in a bet-ter position than an owner to avoid the errors highlighted in these cases, since the Designated Manager is “on the ground” interacting with patients and, in this case, facilities. However, that does not absolve an owner of re-sponsibility. Owners are responsible for the people they hire. If they do not hire competent people and over-see them appropriately, monitor their practice and overall pharmacy oper-ations, and ensure that records are updated, maintained, and audited on a regular basis, the public will suffer. Neither inadequate record keeping nor failure to have proper authoriza-tion can be seen as “administrative errors.” Proper record keeping and ensuring that medication is appropri-ate for the patient are critical to deliv-ering competent patient care and pro-tecting the public.

The drugs in issue in this case were to treat very serious illnesses. The risk of complications arising from on-going unsupervised use of these drugs was high. There was no evidence of patient harm presented to the Panel, and the Panel hoped that no patient harm occurred.

The Panel adopted the comments of the Discipline Panel in the Huh case acknowledging the Member’s acceptance of responsibility and full cooperation in the College’s investi-gation. As in the Huh decision, the Panel was loath for this case to be



perceived as being primarily one of record keeping. The case goes much deeper than that, and it had potential for real impact on patient care.

While it was prepared to accept the Joint Submission on Penalty in this case, the Panel noted that Mr. Chin is currently in Part B of the Col-lege’s register and will only serve a period of suspension if he returns to practice in Part A, which the Panel had been advised was unlikely to hap-pen. The Panel believed that another option in future similar cases may be to increase the costs portion of the penalty or impose a fine in lieu of any suspension.

Order1. A reprimand.2. Specified terms, conditions, or

limitations on Mr. Chin’s Certifi-cate of Registration requiring him to complete successfully, at his own expense, within 12 months of the date of this Order, remedial

training, as follows: (a) CPS I Module 1: Pharmaceut-

ical Care – Applied Therapeut-ics Lecture Series,

(b) CPS I Module 3: Basic Profes-sional Practice Labs; both from the Canadian Pharmacy Skills Program offered through the Leslie Dan Faculty of Phar-macy at the University of To-ronto, and

(c) the Jurisprudence seminar of-fered by the College.

3. A suspension of Mr. Chin’s Certifi-cate of Registration for a period of three months, with two months of the suspension to be remitted on condition that the Member com-plete the remedial training exercis-es specified in paragraph 2, above. The suspension shall commence when the Member becomes eli-gible to return to the practice of pharmacy in Ontario.

4. Costs to the College in the amount of $7,500.

ReprimandThe Panel felt strongly that the ul-timate responsibility for patient care falls on the owner/director of a pharmacy. Being an owner does not absolve a pharmacist of the re-sponsibility to ensure proper care for each and every patient under the pharmacy’s care. The Panel appreciated that the Member ac-cepted responsibility for his actions and agreed to complete courses and evaluations.

The Panel felt that Mr. Chin’s ac-tions impacted on the profession. As a pharmacist, he owes a duty to the profession to maintain a high stan-dard of practice with regard to pro-fessionalism and patient care. The Panel’s understanding was that no harm was done to the patients in-volved, but the Panel considered the interests of the public in ensuring proper health care, safety, and pro-tection. The breach of public trust and faith was unacceptable.


The system used by Health Canada to assign Drug Iden-tification Numbers (DIN) can result in drug products be-ing assigned identical DINs. See Table 1. The potential for dispensing errors involving these products has been discussed in a previous Focus on Error Prevention article (Pharmacy Connection September/October 2004). Phar-macists should also be aware of the potential for billing errors when dispensing these products.

Case:

The following prescription, written for a seventy seven year old patient, was taken to a local community phar-macy for processing.

The pharmacy technician correctly entered the Frag-min® 7500IU / 0.3 ml pre-filled syringes into the com-puter. The claim was transmitted to the Ontario Drug Benefit Program (ODB) for payment using the DIN as-signed by Health Canada (02132648) and the limited use code (LU188) written by the physician. Though Fragmin® 7500IU / 0.3 ml is not a benefit under the ODB program, the claim was paid because the DIN transmitted was iden-tical to the DIN of another Fragmin® pre-filled syringe product that is covered by the ODB program. Due to lim-ited stock levels of Fragmin® 7500IU / 0.3 ml, the phar-macist dispensed 15 pre-filled syringes and the patient’s agent was asked to return the next day for the remaining 15 pre-filled syringes.

focus on error prevention

Ian Stewart, R.Ph., B.Sc.PhmToronto Community Pharmacist

DIN Billing Error

The next day the patient’s agent returned for the re-maining fifteen syringes. On this occasion, a second phar-macist identified the billing error. The claim to the ODB program was therefore reversed and the patient’s agent was informed that the drug product is not a benefit under the ODB program. Though this billing error did not cause direct patient harm, it did create a financial challenge for the patient due to the high cost of the medication. The patient – pharmacist relationship was likely strained as well.

Possible Contributing Factors• The DIN assigned to most Fragmin® pre-filled syringe

products is identical.

Table 1.

Drug Product DIN

Fragmin® 5000IU / 0.2 ml


Fragmin® 10000IU / 0.4 ml 02132648




• There are seven Fragmin® pre-filled syringe products available. The 7500IU / 0.3 ml product is the only one not covered by the ODB program.

• Both the physician and pharmacist assumed that all Fragmin® pre-filled syringes were covered by the ODB program.

Recommendation Educate all pharmacy staff about the potential for er-ror when dispensing products with similar or identical DINs.

The College has previously corresponded with Health

Canada to recommend that efforts be made to assign

a unique DIN to different medication dosages in the

interest of patient safety.


Visit the College’s website: www.ocpinfo.com for a complete listing of upcoming events and/or

available resources. A number of the programs listed below are also suitable for pharmacy technicians.

CE resources

ONTARIOSeptember – November, 2009 (various locations)Enhancing MedsCheck: Best Possible Medication History (BPMH) seminarsInstitute for Safe Medication Practices Canada (ISMP)Contact: Carol Lee at [email protected]

November 10, 2009Family Health Team pharmacist networking day.Contact: Lisa Dolovich ([email protected]) http://www.impactteam.info/events.php

GTASeptember 10-12, 2009Ontario Pharmacists Association (OPA) Annual ConferenceToronto, ONContact: Penny Young @ 416-441-0788 ext. 2209, [email protected]://www.opatoday.com/Confer-ence2009.asp

September 21, 2009Analyzing Medication Incidents Effectively to Enhance Medication Safety Institute for Safe Medication Practi-ces Canada (ISMP )Sheraton Centre Toronto Hotel, 123 Queen St, TorontoContact: Sibylle von Guttenberg @ [email protected]://www.ismp-canada.org

September 23rd, 2009 Advanced Cardiology Pharmacy

Practice Part 1 of 3(Part II online, November 2009, Part III Mar 2010)Leslie Dan Faculty of Pharmacy, University of TorontoContact: Ryan Keay @ 416-978-7562http://cpd.phm.utoronto.ca/cardiol-ogy_pharmacy.html

September 24, 2009Preventing Antimicrobial Re-sistance Through Antimicrobial StewardshipInstitute for Safe Medication Practices Canada (ISMP )Sheraton Centre Toronto Hotel, 123 Queen St, TorontoContact: Sibylle von Guttenberg @ [email protected]://www.ismp-canada.org

September 25-27, 2009Oncology for Pharmacists – Module IITherapy, Pharmacology and Com-mon MalignanciesLeslie Dan Faculty of Pharmacy, University of TorontoContact: Ryan Keay @ 416-978-7562http://cpd.phm.utoronto.ca/oncol-ogy.html

October 1-4, 2009Asthma and COPD Patient Care – CAE/CRE Preparation CourseOntario Pharmacists AssociationBMO Institute for Learning, 3550 Pharmacy Avenue, TorontoContact: Penny Young @ 416-441-0788 ext. 2209, [email protected]://www.opatoday.com/CE_A-COPD09.asp

October 17-18, 2009Clinic Days Ontario Pharmacists Association BMO Institute for Learning, 3550 Pharmacy Avenue, TorontoContact: Penny Young @ 416-441-0788 ext. 2209, [email protected]://www.opatoday.com/CE_A-COPD09.asp

October 19-21, 2009 (In French)Cours sur l’arret du tabagisme: com-petences et strategies essentielles.Canadian Association for Mental Health (CAMH)Contact: [email protected] or Tel:416-535-8501 ext. 1600

October 29, 2009The 10 minute Patient Interview Faculty of Pharmacy, University of Toronto and MTPASpirale Banquet Hall, North YorkContact: MTPA @ 416-855-9268e-mail: [email protected]

Fall 2009Natural Health Products Certificate Program Ontario Pharmacists Association http://www.opatoday.com/webinar.asp for date and time

ON-LINE/ WEBINARShttp://www.rxcertified.ca Online fee-based certificate courses developed by the Drug Information and Research Centre (DIRC) and rx-BriefCase.com. Currently available:- Diabetes Patient Care Level 1- Obesity Program


laws & regulations

Drug and Pharmacies Regulation Act (DPRA) * sJune 4, 2008 Regulations to the DPRA:Regulation 545 – Child Resistant PackagesRegulation 297/96 Amended to O.Reg. 173/08Regulation 551 Amended to O.Reg. 172/08

Drug Schedules **Summary of LawsJune 2007 OCPNational Drug Schedules (NAPRA) July 16, 2009 (or later)Advance Notice: Schedule F amendmentsEplerenone, Desvenlaxine and its salts, Fosaprepitant and its salts. Recent amendments to National Drug Schedules (NDS):Naproxen Sodium 220mg – June 2009Proposed schedule changes by NDSAC:Methocarbamol Diphenhydramine and its salts

Regulated Health Professions Act (RHPA) * sAmended June 4, 2009 Regulations to the RHPA:Regulation 39/02 - Amended to O.Reg. 666/05Regulation 107/96 – Controlled ActsRegulation 59/94 – Funding for Therapy or Counseling for Patients Sexually Abused by Members

Pharmacy Act (PA) & Regulations * sJune 2007 Regulations to the PA:Regulation 202/94 Amended to O.Reg. 270/04Regulation 681/93 Amended to O.Reg. 122/97

Standards of Practice sStandards of Practice for Pharmacists, 2003Standards of Practice for Pharmacy Managers, 2005Standards for Pharmacists Providing Services to Licensed LTC Facilities, 2007.

Drug Interchangeability and Dispensing Fee Act (DIDFA) & Regulations * sJune 2007 Regulations to the DIDFA:Regulation 935 Amended to O.Reg. 354/08Regulation 936 Amended to O.Reg. 205/96

Ontario Drug Benefit Act (ODBA) & Regulations * sJune 2007 Regulations to the ODBA:Regulation 201/96 Amended to O.Reg. 252/09

Controlled Drugs and Substances Act & Regulations (CDSA) **Act current to July 12, 2009All regulations current to July 29, 2009Benzodiazepines and Other Targeted Substances Regulations Marihuana Medical Access Regulations Narcotic Control Regulations Precursor Control Regulations Regulations Exempting Certain Precursors and Controlled Substances from the Application of the Controlled Drugs and Substances Act

Food and Drugs Act (FDA) & Regulations ** 'Act current to July 12, 2009Amending FDA Regulations, Project 1590 - Lenalidomide to Schedule F (May 13, 2009) Amending FDA Regulations, Project 1584 - Naproxen and salts to Schedule F (May 13, 2009) Amending FDA Regulations, Project 1583 – 6 medicinal ingredients and salts to Schedule F (May 13, 2009) Amending FDA Regulations, Project 1578 – 4 medicinal ingredients and salts to Schedule F (May 13, 2009) Amending FDA Regulations, Project 1540 - Dasatinib, Deferasirox, Lumiracoxib, Posaconazole and Telbivudine to Schedule F (May 13, 2009)

OCP By-Laws By-Law No. 1 – June 2009 sSchedule A - Code of Ethics for Members of the Ontario College of Pharmacists - December 2006Schedule B - “Code of Conduct” and Procedures for Council and Committee Members - December 2006Schedule C - Member Fees - January, 2009Schedule D - Pharmacy Fees - January, 2007Schedule E – Certificate of Authorization – January 2005Schedule F - Privacy Code - December 2003

Reference sOCP Required Reference Guide for Pharmacies in Ontario, May, 2009

* Information available at Publications Ontario (416) 326-5300 or 1-800-668-9938 www.e-laws.gov.on.ca ** Information available at www.napra.org ' Information available at Federal Publications Inc. Ottawa: 1-888-4FEDPUB (1-888-433-3782)

Toronto: Tel: (416) 860-1611 • Fax: (416) 860-1608 • e-mail: [email protected] s Information available at www.ocpinfo.com

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Looking Back… As Our Profession Advances

Photo taken at the Niagara Apothecary - One of Canada´s first retail pharmacies – located in Niagara-on-the-LakePhotographer – Mathew Rossi

September/October 2009

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Transcript of September/October 2009