Pharmacist guilty of negligence after a patient misused a medication

Although the disciplinary complaint was filed on January 7, 2025, the allegations against pharmacist Heba Zalat date back to February 2024. The patient is a master's student residing in Europe who was visiting his mother in the suburbs of Montreal for a few weeks. During his stay, he received several prescriptions related to treatments for asthma and lactose intolerance, as well as, following a diagnosis of anogenital condylomas, a compounded preparation of 50%-90% trichloroacetic acid in 70% alcohol, to be applied once a week for six weeks.The prescriptions were sent to the pharmacy where Heba Zalat worked and where the patient's mother had been going for several years. The acid solution, which had to be prepared by another pharmacy, was delivered to the pharmacy a few days later. The label on the glass bottle and its plastic container did not contain any specific warning about the dangerous nature of the product.'Worst pain of his life'The patient's mother, a long-time customer, picked up the medication on behalf of her son, who wanted to avoid unnecessary outings and did not have a working Quebec phone number. At this point, the pharmacist noticed that the mother was very curious about the product, which made her uncomfortable. She knew that the patient could not be reached by phone. She asked the mother if her son knew how to use the medication, to which the mother replied affirmatively with confidence. The pharmacist then explained that she had deliberately been vague in order to maintain patient confidentiality.When he receives the acid solution from his mother, the patient found no explanatory leaflet accompanying the product. As he saw no warning on the bottle label, he did not believe the product to be dangerous. He squeezed the contents of a pipette onto his entire genital area, without protecting the healthy skin with oil and without wearing gloves, and rubbed the solution in with his other hand. He then panicked and screamed. He said he was experiencing, “the worst pain of his life.”Council's analysisWith regard to the sole count of the complaint, Heba Zalat entered a plea of not guilty. However, the Disciplinary Council found the pharmacist guilty of contravening sections 38 and 77(1) of the Code of Ethics, as well as section 59.2 of the Professional Code.Section 38 requires pharmacists to provide their patients with the explanations necessary to understand and appreciate the pharmaceutical services they provide. Section 77(1) specifies that negligence in the practice of the profession constitutes an act derogatory to the dignity of the profession. Finally, section 59.2 prohibits any act that is derogatory to the honor or dignity of the profession or to the discipline of the members of the Order. The Council stated that the pharmacist “should have, under the circumstances, refused to give the acid solution to the mother and insisted that the patient come to see her in person so that she could provide him with the necessary explanations.”However, the pharmacist members of the Disciplinary Council disagreed with the position of the complainant, former deputy trustee Bernard Deshaies. They were of the opinion that treatment should begin quickly and that there was no reason to withhold the medication in these circumstances. The Council found the pharmacist guilty on July 31, 2025. The penalty will be determined at a subsequent hearing.Deputy trustee resignationMeanwhile, Deshaies, who had been deputy trustee for more than six years, resigned from his post on September 30, according to the Quebec Order of Pharmacists.Since the summer of 2025 in particular, pharmacist owners and organizations had publicly expressed a loss of confidence and denounced decisions deemed too severe by the disciplinary board. There was particular objection to the sanctions imposed on two pharmacists in the followup of a vulnerable patient.Since 2019, Deshaies had been supervising disciplinary investigations and ensuring the application of the ethical rules for pharmacists as deputy trustee. He had previously been a corresponding trustee for nearly three years and a member of the Order's Disciplinary Council since 2003.Professional bodies representing several professions have called for the imposition of a code of ethics for trustees in order to regulate their powers and increase the transparency of the professional disciplinary process. This project has not yet been implemented.Among pharmacists, disciplinary investigations are criticized in particular for their length and the methods used, which can sometimes be perceived as humiliating. The fact that a disbarred pharmacist owner must sell their pharmacy is another contentious issue.Read: Two pharmacists sanctioned for serious failures in monitoring a patientRead: Disciplinary sanctions for lack of file notes: 'It created unease and fear'Read: Message from the OPQ president: Towards a better understanding of disciplinary decisions

Pharmacist guilty of negligence after a patient misused a medication

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