'Lack of judgement': Pharmacist mistakenly thought 'SS' meant super strength and assumed others would check for drug interactions

A Québec pharmacist who erroneously assumed the letters “SS” in a prescription meant “super strength” and dispensed the double-dosage version of an antibiotic to a patient undergoing hemodialysis has been fined $8,000 and called out for failing to take full responsibility for her mistakes. Chau Vien Linh Ngo works in a pharmacy in Longueuil, Que., and has been practising in the province since 2006. According to the decision document issued by the discipline council of the Ordre des pharmaciens du Québec, she also failed to discuss with her patient the potential for interactions between the antibiotic she had dispensed—Sulfatrim-DS—and the Coumadin warfarin he was already taking. Instead Ngo assumed that this interaction would be addressed by the clinic where the patient, who suffers from kidney failure and phlebitis-thrombophlebitis, was going for hemodialysis and which knew that he was taking Coumadin. Read: Right dosage, wrong drug: Patient lands in ER after pharmacist misreads prescription “The pharmacist is responsible for monitoring the medication she dispenses,” wrote the discipline council. “She cannot seek to share the blame with the medical clinic as she suggests in her testimony. The respondent must realize that it is up to her to do all the verifications and all the follow-ups required and that she can never take it for granted that others will do it for her.” Ngo attributed her dispensing mistake to her misunderstanding of the letters “SS,” which meant “single strength” and not “super strength.” She told the council she had never before encountered this acronym and was, instead, familiar only with the abbreviation “reg.” for regular strength. Shortly after the patient started taking the antibiotics, his international normalized ratio increased and he began having nosebleeds. An attending physician discovered he was taking Coumadin and antibiotics and ordered that he stopped the latter. In arriving at its decision, the discipline council pointed out that Ngo should have clarified with the prescribing physician the meaning of the letters “SS” but took no steps to do so. She also should have evaluated the potential for drug interactions. Read: Don't try this at home: Pharmacist slammed for vaccinating patients in his own residence “When taking a drug concomitantly with Coumadin, the dose of the latter may need to be adjusted to take this into account,” wrote the council. “Since the potential for drug interaction is high with Coumadin, these should be evaluated by the pharmacist with analyzing drug therapy.” While Ngo admitted and expressed remorse for her mistakes, the council noted that she displayed a “lack of judgment” that ran counter to her years of experience and that her risk of recidivism appeared high. “Mentioning that she will be more vigilant in the future seems insufficient, because she had the relevant information and she made an error in judgment,” wrote the council. “For example, she does not mention having registered for training or taking special measures in the filing of files in the case of vulnerable patients, she does not suggest changes in her workload. Let us not forget that the patient, in this case, is vulnerable and that she will be called upon to serve other patients whose state of health is fragile.” Read: An honest mistake with distressing consequences: Pharmacist gives contraceptive to patient trying to have a baby

'Lack of judgement': Pharmacist mistakenly thought 'SS' meant super strength and assumed others would check for drug interactions

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