Two pharmacists sanctioned for serious failures in monitoring a patient

A vulnerable patient had to be hospitalized in intensive care, then placed in a residence due to his loss of autonomy, following several failures in his care and followup by his usual community pharmacy, according to a recent decision by the disciplinary board of the Ordre des pharmaciens (OQP).As a result, owner-pharmacist Said Khaouam and one of his salaried pharmacists, Eugénie Juljulian Saour, have just been fined $5,000 and $4,500—on the joint recommendation of the parties—for serious negligence in dispensing medication and monitoring a vulnerable patient. The salaried pharmacist has not been registered with the Ordre des pharmaciens since March 28, 2025, and has also undertaken not to re-register in the future.Anticoagulant to be closely monitoredThe facts date back to October 2023. The patient, a 77-year-old man, was a regular customer of the Familiprix Said Khaouam pharmacy in Montreal. He even considers the pharmacist-owner and his wife “family.”Long treated with rivaroxaban, his family physician changed his medication in August 2023 to apixaban 5 mg twice daily following hospitalization.Apixaban, an oral anticoagulant used to prevent the risk of stroke, requires heightened vigilance and regular intake, and Quebec guidelines state that it is, “essential to provide positive reinforcement of compliance with treatment and negative impact if it is not, and that adherence to treatment should be checked at each visit, or . . . at each renewal.”The vulnerable patient in question has recurrent problems of medication non-adherence, which were well known to his community pharmacy.In addition to this treatment, the patient needed to take Mint-Atenol® (atenolol) 25 mg once daily for his hypertension, and ferrous sulfate 300 mg once daily. All these medications needed renewing every month.No refills for two monthsNormally, the patient's wife or daughter would call the pharmacy to renew his medication, which was then delivered directly to his home.The owner-pharmacist first dispensed the apixaban on Au. 5, then on Sept. 2 and Oct. 3, 2023.The pharmacist assured the trustee that he had reminded the patient's wife of the importance of taking the medication regularly, as directed. The report from the disciplinary board points out that, “Non-compliance with drug therapy by the vulnerable, multi-medicated patient, who is known to the respondent, is serious and grave, and should have been a warning signal for the pharmacist.” However, Khaouam did not take care to contact his patient's family doctor in connection with this non-compliance.The next renewal was filled by the salaried pharmacist only on Nov. 18, 2023, some 16 days late. One month later, on Dec. 18, 2023, the owner-pharmacist renewed other drugs for the patient, but not the apixaban. Ten days later, it was the same story: The salaried pharmacist renewed two drugs in the patient file, but not the apixaban. On January 10, 2024, the owner-pharmacist renewed only the clonazepam and not the apixaban.The next day, when analyzing the patient file for a new prescription for Clavulin, Khaouam did not follow up on the delay of apixaban, nor did he make any note in the patient file.On Jan. 17, the patient's wife refused to renew the apixaban prescription, stating that her husband didn't need it at the time. The patient had therefore remained without apixaban for two months.In this case, “not only did the respondent delay the renewal of three drug therapies, or forget to renew them at all, he also failed to record any notes in the file enabling other pharmacists to follow up,” reported the board in its decision. Further, according to the trustee, the owner-pharmacist also failed to follow up on delays in renewing prescriptions for Mint-Atenol and ferrous sulphate (no renewal since Nov. 18, 2023).Five days later, on Jan. 22, the patient was admitted to intensive care at Laval's Hôpital de la Cité de la Santé for altered consciousness requiring intubation. A CT scan showed a frontal ischemic lesion consistent with a cardioembolic stroke. The 77-year-old patient has been in a vegetative state ever since and has had to be institutionalized.The disciplinary board's decision report emphasizes that, “The actual consequences of the omission [of the pharmacist-owner and the salaried pharmacist], regarding apixaban and other medications, are serious, grave and irreversible. [The patient] suffered a stroke that required hospitalization and left him in a vegetative state. He now finds himself in a long-term care facility, having lost all autonomy.”Not simply a ‘medication dispenser'The trustee’s office was alerted by a pharmacist assigned to the hospital's intensive care unit, who became aware of the treatment disruption by analyzing the patient's medication reconciliation.In its decision, the disciplinary board noted several aggravating factors against the pharmacist-owner and his salaried pharmacist. First, their extensive professional experience at the time of the events—20 and 35 years of practice respectively. Secondly, the serious consequences for the patient, who was already vulnerable and multi-medicated, and who was not respecting his therapy.Indeed, “The pharmacist who serves drug therapies to a patient assumes responsibility for ensuring the required followup, unless he or she has ensured that a colleague or another professional has taken charge of the patient,” stated the decision.No communication with FPThe two professionals are also accused of having not approached the family doctor, of not having considered the warning signals concerning this patient, and of not having followed up on the electronic file. The pharmacist's role, "is not limited to selling patient medicines, and his or her actions cannot be purely mechanical. The pharmacist is not simply a ‘drug dispenser’," the board reiterated.Finally, unlike the salaried pharmacist, the owner-pharmacist committed repeated acts, since a total of three drugs were not served to the patient.However, several mitigating factors were found in favour of both pharmacists: Their respective guilty pleas and sincere regrets, as well as their lack of disciplinary history.In addition, the pharmacist-owner now says he uses a software program in his pharmacy for reminding patients of renewals and entering notes in the file, as well as an electronic diary. He says he contacts the family doctor in the event of non-compliance and asserted that he no longer relies on his patients' families.This article has been translated from its original French and first appeared on our sister site Profession Santé.

Two pharmacists sanctioned for serious failures in monitoring a patient

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