A case of mistaken assumptions: Pharmacist's failure to do his own checks leads to patient going into anaphylactic shock

It was an honest case of mistakenly assuming other people had already carried out the necessary safety checks. But in the end the Québec pharmacist who validated a prescription that led to a cancer patient going into anaphylactic shock was found guilty of failing to verify the risk of allergy, as well as failing to provide the appropriate advice related to the dispensed medications. Quoc Nguyen, who practises at a Jean Coutu pharmacy in Montreal, must pay a $6,000 fine plus investigation and hearing costs, according to the decision document issued by the Ordre des pharmaciens du Québec. During the investigation, Nguyen admitted right away that he should have rechecked the patient’s prescription for the drug Lapelga, which was distributed in pre-filled needle caps containing natural rubber latex. He also should have counselled the patient on two other medications, prochlorperazine and dexamethasone, that had been prescribed to her. Nugyen acknowledged that he should have carried out his own “checks and procedures regarding the patient’s allergy to latex” and that he should have talked to the patient “in order to give her the usual advice with the prescriptions that were served to her that day.” Read: Toxic mistake: Pharmacist puts once-a-week drug in daily pillboxes Instead he assumed that a pharmacist at another Jean Coutu location—where the Lapelga prescription had initially been sent to by mistake—had verified the risk of latex allergy. Nguyen also assumed the pharmacist who ultimately handed the patient her medications had provided counselling on the drugs. But neither of these two other pharmacists had spoken to the patient, although the one who first received the prescription had tried, unsuccessfully, to contact the patient by phone. A pharmacy technician at the same pharmacy had noted earlier that the phone number on file for the patient was not in service. The patient has been a customer since 2012 at the Jean Coutu location where Nguyen worked and her latex allergy was clearly indicated on her patient file, according to the decision document. On Dec. 17, 2021 the patient went to a community service centre, where a nurse administered an injection of Lapelga. Shortly after she was taken to the emergency room of the Hôpital Notre-Dame for anaphylaxis, with symptoms that included difficulty breathing, swelling of the lips and throat, itching, nausea and abdominal pain. She was discharged from the emergency room at the end of the day. Read: Right label, wrong meds: Patient trying to get pregnant gets drugs that stop hormone production While taking into account Nguyen’s early admission of guilt and full cooperation with the investigation, the council noted that a “a clear message should be sent to other members of the profession as to the importance of being extra vigilant when filling prescriptions for a patient suffering from of an allergy. The consequences of a pharmacist's negligence on the state of health of his patients can be major.” Pharmacists cannot assume, as Nguyen did, that other pharmacists will check and ensure the appropriate use of a medication, the council wrote in its decision “Patient health is at stake. In this case the (pharmacist) has failed in his obligations. He did not contact the pharmacist at the first branch or the patient.” Read: Health Canada warns of dangers of water beads

A case of mistaken assumptions: Pharmacist's failure to do his own checks leads to patient going into anaphylactic shock

Register for free access or login.

Related Topics