A tough situation in a remote area: Overwhelmed pharmacist penalized for a series of negligent acts

In a decision published on July 23, the Disciplinary Council of the Quebec Order of Pharmacists (OPQ) fined pharmacy owner Olga Domkem Nkemaigni a total of $13,000 for a series of negligent acts in the care of several patients.Nkemaigni, a member of the Order since 2013 and practicing at her pharmacy in Lebel-sur-Quévillon, in the James Bay region, faced several charges, as reported by Profession Santé in a previous article.The pharmacist-owner failed to obtain the necessary information or provide the necessary explanations to two vulnerable patients when dispensing prescriptions for several eye drops and one injectable medication; and she was negligent in allowing an elderly patient to be given a pill organizer that did not correspond to new prescriptions, without making any note of this in the patient's file.All these instances of negligence occurred between April 2024 and January 2025. During this period, Nkemaigni states she was practicing her profession "under difficult conditions and with a small team, or even alone." Indeed, she faced a labour shortage exacerbated by evacuations related to the forest fires that ravaged the region during the summer of 2023, and difficulty recruiting replacements in such a remote area."She states that she has never stopped trying to hire staff and that she feels she has started over 10,000 times since becoming the owner," the report reads.Despite these circumstances, the pharmacist-owner maintains that she is committed to serving her patients.Recap of the eventsInitially, at the beginning of 2024, the pharmacist-owner failed to dispense eye drops for the right eye of a 73-year-old patient following cataract surgery and never provided the prescribed antibiotic. This delay and lack of follow-up reportedly caused an eye infection in the patient.Then, in October 2024, Nkemaigni dispensed an injectable medication to a 61-year-old disabled patient who had undergone hip surgery without providing the necessary syringes and needles. She also failed to ask any questions or provide any instructions regarding the administration or storage of the medication, and provided an incomplete label.Finally, in January 2025, the pharmacist forgot to change the prescription in an elderly patient's pill organizer. As a result, the patient took her old medication for two days. Although the pharmacist corrected the pill organizer after being alerted by the nurse at the residence where her patient lived, she made no note of it in the patient's file.In her defence regarding these various errors, Nkemaigni cited, among other things, high customer volume at her pharmacy and a reduced staff.Several warnings already issuedAlthough she has no prior disciplinary record, the pharmacist-owner had already received warnings in 2022 and 2023 for similar situations. During the closure of a total of 12 investigation files, the professional order highlighted, in particular, "certain issues that could impact the quality and safety of pharmaceutical services provided," and a "lack of organization of activities leading to service disruptions for some patients and breaches of confidentiality, the absence of comprehensive therapy management, and deficient prescription management during dosage changes."The pharmacist-owner had also been the subject of various professional inspections since 2019. A 2022 inspection report on the medication circuit indicated, in particular, that "the management of pill organizer changes is deficient and that administration aids are lacking."Two years later, an inspector also deemed that providing patients with the necessary information to enable them to use their therapy effectively and safely was "at risk."At the time, the pharmacist-owner had already cited her challenging working environment and several personal factors to explain these shortcomings.Council decisionIn its decision on guilt and sanction, the Disciplinary Council reiterated "the intrinsic seriousness of the alleged offences" and took into account several mitigating and aggravating factors, including:the risk of recidivism highlighted by the complainant, assistant Syndic Naji-Tom Samaha;the fact that Nkemaigni pleaded guilty and cooperated with the various investigations;the implementation of the Empego software in her pharmacy following the various complaints;the delegation of tasks to staff to focus more on prescription validation, patient notes, and follow-up;the prompt recording of prescriptions in the patient's file by technical staff.Because the imposed sanctions must "have a deterrent effect" and "act as preventative tools," the Council decided to follow the joint recommendations of the parties and impose four fines on the pharmacist-owner, ranging from $3,000 to $4,000, for a total of $13,000, thus preventing her from having to sell her pharmacy and causing a disruption to service in her community.Those interested can consult the Disciplinary Council's decision on this case in full here (although it is only available in French)This article has been translated from its original French and first appeared on our sister site Profession Santé.

A tough situation in a remote area: Overwhelmed pharmacist penalized for a series of negligent acts

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