Ontario pharmacist who dispensed antidepressants instead of acid reflux drug loses his appeal

An Ontario pharmacist who dispensed the wrong medication will need to complete additional training after a provincial appeal board upheld a decision by the Ontario College of Pharmacists (OCP).In a decision dated Oct. 14, the Ontario Health Professions Appeal and Review Board confirmed that Attia Abd El Malek must complete a medication error prevention course and undergo follow-up remediation. The case stems from a February 2024 incident in which a patient was given paroxetine 20 mg, an antidepressant, instead of rabeprazole, which had been prescribed for acid reflux. According to the college, the patient picked up the incorrect medication without an information sheet, which she found odd. The error was discovered the following day, when Abd El Malek called her after noticing she appeared on a report identifying patients who had missed counselling.The patient told him she had not taken the medication because she did not have depression or anxiety. Rather, she had been prescribed medication for acid reflux.“The pharmacist wasn’t even aware of the error until he started to explain to me over the phone about the medication I’d picked up,” said the patient in an email to the college.Error could have been caught with a seven-point checkWhile Abd El Malek apologized for the mistake and arranged to retrieve the incorrect medication, the college's complaints committee found that although a pharmacy assistant entered the wrong medication, Abd El Malek was “ultimately responsible for ensuring the accuracy of the prescription information entered.”The committee said the error would have been caught if he had completed a seven-point check comparing the original prescription with the information entered into the pharmacy system, “including verifying the medication name.”It also criticized his response to the incident, finding that his analysis failed to adequately explain why verification steps were missed.Abd El Malek had appealed the college’s judgement, arguing that the additional training was disproportionate given his lack of previous complaints and the corrective steps he had already taken. He also argued that the required course was “redundant” because he had already undertaken medication safety training.The board disagreed, citing the college's finding that Abd El Malek had made a “significant dispensing error” without completing a “fulsome root cause analysis.”Abd El Malek will need to complete the Ontario Pharmacists Association's Preventing and Analyzing Medication Errors Online Course, followed by remediation with college staff within 24 months of completing the course.

Ontario pharmacist who dispensed antidepressants instead of acid reflux drug loses his appeal

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