Pharmacist mistakenly dispenses Suboxone to elderly patient, sends him to ER

On April 1, 2023, a patient, aged 77, went to a pharmacy in Rivière-du-Loup to renew his prescription for Sublinox 10 mg, a medication he takes as needed to help him sleep. The medication was ready, packaged the day before in a transparent bag by the pharmacy technician. All that remained for the employed pharmacist present that day was to verify that it was the correct medication for the patient. But the latter did not open the plastic bag to check the contents. He simply read the label affixed to the bag, which clearly indicated "Sublinox 10 mg." So he did not notice that the transparent bag contained not the prescribed sleeping pill, but Suboxone 12 mg, a medication indicated to treat opioid addiction.Pacemaker insertion following complicationsThe pharmacist on duty, who has 46 years of experience, then dispensed the medication to the patient, who took it home. It was only three months later, on July 11, 2023, that the patient took half a tablet of what he believed to be his usual sleeping pill, at bedtime, around 10:30 p.m. The septuagenarian had in fact just ingested half a tablet of Suboxone 12 mg, or 6 mg of the drug, the usual recommended initial dose of which is 2 to 4 mg."The next morning, July 12, 2023, the patient woke up and asked his wife to help him get up, he was then unable to walk without assistance. He suffered from increased sweating, chills, tremors, nausea, vomiting and blurred vision," states the disciplinary decision issued against the pharmacist. The patient's wife decided to return to the pharmacy that dispensed his medication in April to have her husband's medication checked. The pharmacist on duty informed her the medication is not Sublinox, but Suboxone, and that the patient must be taken to the hospital immediately and the Quebec Poison Control Centre contacted. For her part, the pharmacist fills out an accident-incident report. Read: Manitoba’s Safety IQ outlines 6 steps for quality improvementThe patient had to be hospitalized for 13 days, and "complications related to this hospitalization lead to the insertion of a pacemaker," the decision reports. The pharmacist, a member of the Order since 1978, pleaded guilty after apologizing to the patient's wife. He admited to not having opened the transparent zip bag to check that it was indeed Sublinox. Suboxone now stored in secure cabinetThe pharmacist explained that at the time, Sublinox and Suboxone were placed next to each other on the shelf—hence the misunderstanding. "Since then, following its intervention with the owners of the pharmacy, the Suboxone has been kept in the narcotics cabinet," the decision stated. The pharmacist also now says he has changed his practice, and checks the medications in the transparent bags more thoroughly, without being interrupted.In the end, the two parties agreed on a joint recommendation of a $4,500 fine, which was accepted by the disciplinary council of the Ordre des pharmaciens du Québec. Several aggravating factors were identified:"The objective seriousness of the offence, because it lies at the heart of the profession. Indeed, providing the prescribed medication constitutes an obligation of result for a pharmacist, any error in this regard results in a loss of public confidence in the profession;The respondent's long professional experience of 45 years at the time of the event; andThe great vulnerability of the patient and the consequences on his health.”But the disciplinary board also took into consideration the pharmacist's sincere regret and lack of prior record, as well as the measures put in place to prevent such negligence from happening again in the future. Read: Watch out for these three common errors with diabetes medicationsThis story has been translated from its original French and first appeared on our sister website, ProfessionSante.ca

Pharmacist mistakenly dispenses Suboxone to elderly patient, sends him to ER

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