Errors are “Expected to be a Part of the Learning Process for a Pharmacist” Says Court

This month, we look at the issue of errors, specifically, punishment for errors. A Rhode Island court was asked to decide whether the Director of the Rhode Island Department of Health erred when he revoked a pharmacist’s license to practice after a compounding error. The case was further complicated by the fact that the State Board of Pharmacy, after an administrative hearing, recommended that the pharmacist only have his license temporarily suspended.

The Facts

The story began when the Board of Pharmacy received a call from a mother who reported a dispensing error and wanted to file a complaint. The prescription she had picked up for her child, compounded by the pharmacist and labeled as being liquid omeprazole contained morphine. The mother took her child to the hospital after becoming concerned about the child’s lethargy and at the hospital it was discovered that the compounded heartburn medication the child was taking contained morphine. After additional testing confirmed that morphine was in the compounded medication, the Compliance Director of the Pharmacy Board performed a full inspection of the compounding pharmacy.

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The inspection revealed numerous problems in the pharmacy, including: clutter and disorganization, no organized pattern for where drugs were located, medications haphazardly placed on shelves on top of one another, and look alike/sound alike medications stored next to each other.

The Hearing

The pharmacist and the Board of Pharmacy agreed to a one-year suspension of the pharmacist’s license, but the Director of the Department of Health rejected this and eventually the case ended up in front of an administrative Hearing Officer who held hearings to gather evidence and issued a judgment regarding the pharmacist’s violations.

At the hearing, the pharmacist testified that he’d been practicing pharmacy for 33 years, that he served as President of his state pharmacy association, and that he had served on the Rhode Island Senate for 18 years and on the Department of Health Board of Pharmacy for 12 years. He further testified that he estimated that he had filled close to two million prescriptions in his career.

The pharmacist testified that the disorganization seen by the Board of Pharmacy inspection was due to the fact that the investigation occurred on one of the busiest days of the week when the pharmacy becomes inundated with orders awaiting check, packaging and shipping. He noted that it was critical for the pharmacy’s “especially vulnerable patients to receive their medicine in a timely fashion, especially after the weekend when the pharmacy is closed.” As a result, the pharmacist argued, the clutter observed by the investigators was caused by the large number of orders being processed at the same time.

However, the pharmacist also admitted that the adulterated omeprazole was the result of this disorder at the compounding station. A bottle of morphine concentrate used for hospice patients was likely left out on the counter, and the morphine and flavored sweetening syrups were in identical bottles. In addition, because the morphine was red and the flavoring solution was reddish-orange, the pharmacist wouldn’t see the difference.

In her decision, the Hearing Officer recommended a 30-month license suspension for the pharmacist (with 15 months stayed), two years of probation and continuing education. The Director of the Department of Health disagreed, and revoked the pharmacist’s license permanently.

Court Decision

The pharmacist appealed, and the case went to the Rhode Island Superior Court. The Court noted that the pharmacist had given “lengthy explanations of newly installed safety measures.” It also noted that the Hearing Officer had found that the pharmacist credibly established the cause of the error and had implemented procedures to avoid such an error in the future.

“Pharmacists cannot be held to a standard of perfection,” the court wrote. “Dispensing errors do occur and are expected to be a part of the learning process for a pharmacist.” The court noted the pharmacist’s history as an upstanding member of the pharmacy community for over three decades, and his work with the State Pharmacy Association. Most importantly, the court mentioned that there was no evidence of unwillingness of the pharmacist to reform his policies at the pharmacy or that his dispensing error was willful. The court found that the Director of the Department of Health had acted in excess of his statutory authority and abused his discretion in revoking the pharmacist’s license. The Hearing Officer’s recommendation of a license suspension, probation and continuing education was ordered.

The Takeaway

No one is perfect, and errors can be a learning opportunity. However, you can reduce your chance of compounding errors by: ensuring look alike/sound alike drugs are kept far away from each other, clear labeling of medication, proper storage, double-checking ingredient labels when compounding, and keeping the compounding area orderly.     

Ann W. Latner, JD, is a freelance writer and attorney based in New York. She was formerly Director of Periodicals at the American Pharmacists Association.