Pharmacist suspended, fined after leaving unlabelled drugs at fast-food restaurant for patient

CBC

6 days ago

A Winnipeg pharmacist who left unlabelled prescription drugs in an unmarked bag for pickup with an employee at a fast-food restaurant has been disciplined for professional misconduct.
One of the medications was in the narcotic category, according to a decision recently released by the College of Pharmacists of Manitoba.
An investigator with the regulatory body for pharmacists found the case revealed issues with narcotic accountability and with dispensing frequent and high doses of opioids.
The case goes back to 2019, when the college received a police report about the pharmacist leaving the unlabelled drugs at a Dairy Queen restaurant.
The pharmacist had been contacted by a patient who had pain and fever following dental surgery, says the decision by a College of Pharmacists discipline committee.
A nurse practitioner had prescribed the patient naproxen (an anti-inflammatory sold under brand names like Aleve), clindamycin (an antibiotic) and Tylenol No. 3 with codeine, which is classified as a narcotic, the decision says.
The prescription was faxed to the pharmacy, which was closed at the time, but the pharmacist drove there and prepared medications for the patient.
The pharmacist took the unlabelled drugs in an unmarked bag to a nearby Dairy Queen and handed it to "a young employee" of the restaurant, the decision says.
"She did not confirm the name of the DQ staff member nor did she make any attempt to confirm that the staff member was familiar with [the] patient," according to the decision.
The pharmacist then sent a text to someone — whose name is redacted in the report — saying "meds done and delivered."
It's not clear from the decision why the pharmacist took the medications to the restaurant, as opposed to another location.
Escorted back to pharmacy by police
A person, whose name is redacted, arrived to pick up the prescription, but the Dairy Queen owners refused to release the medications, the decision says.
Police were then contacted and arrived at the restaurant. The pharmacist also returned there, after which police escorted her back to the pharmacy. She attached prescription labels to the medication bottles, which police then delivered, the decision says.
It says the panel found the pharmacist's actions contravened the requirement under Canada's Narcotic Control Regulations to ensure that all drugs "are secured against theft, loss or diversion."
The regulations also require that if a drug is a narcotic, the packaging must have a warning sticker, and the patient must be given an information handout specific to the narcotic being sold, the decision says.
After the incident, the pharmacist voluntarily surrendered her licence to practise and resigned as manager of the pharmacy. Her licence was reinstated by the college's complaints committee in September 2020.
However, the decision says the pharmacist was "found to be practising as a pharmacist in the dispensary at the pharmacy" while her licence was voluntarily surrendered. That resulted in an additional disciplinary charge.
A hearing into disciplinary charges against the pharmacist was held in December 2023, where she entered guilty pleas to multiple counts under the Pharmaceutical Act. The complaints committee entered a stay for some of the counts.
The pharmacist was ordered to pay $150,000 in penalties, including a fine of $20,000 and $130,000 toward the costs of the investigation and hearing.
She was given a one-year suspension from practice, but was given credit for 10 months of the time during which she had voluntarily surrendered her licence.
Sorry for mistake: pharmacist
The discipline panel issued its decision in March 2024, but the pharmacist then filed an appeal at the Manitoba Court of Appeal.
The appeal was discontinued in April 2025, and the regulatory body published the case on its website a few weeks later.
Neely Hammerberg, a communications co-ordinator for the pharmacists' college, said in a statement to CBC the discipline panel issued an order "to publish and make available to the public the decision, which serves to protect the public and uphold transparency and trust in the pharmacy profession."
CBC also contacted the pharmacist after the decision was released.
"I'm sorry for making the mistake," she said, adding that she's working with the college on the guidelines she's been given.
"All I wanted was what is best for my patient," she said. "My patients are still my priority, and their care is still my priority, and I'll continue working towards fixing my practices."
In addition to the Dairy Queen incident, the college's investigation also found the pharmacy where the pharmacist worked had a counselling room for patients, which was described as having prescription files stacked nearly to the ceiling.
Using that room for patient consultations "put the confidentiality of patient information at risk," because the labels of prescription bags contained confidential health information, the decision said.
The counselling room also had a large narcotic safe, which was left unlocked and open, according to the decision.
Anyone coming in through the building's back door "had a view of the interior of the narcotic safe, with nothing to stop them from accessing narcotic storage," it says.
The investigation also found that the pharmacy didn't keep accurate counts of drugs in its inventory of narcotic and controlled substances.
Narcotic counts completed at the pharmacy "revealed that there were significant unexplained drug shortages," the decision says.
It also says the pharmacy dispensed a lot of opioid prescriptions for many patients, with some at very high doses.
The pharmacist had no documentation to show she had been working with prescribers to lower patients' high doses of opioids, and admitted she didn't meet her professional obligations on that, the decision says.
The March 2024 decision notes the pharmacist had previously been disciplined, while practising as a pharmacist in British Columbia.
In 2012, the College of Pharmacists of British Columbia found she had prepared "a fraudulent employment document under the letterhead and purported signature of her current employer," which she then submitted to a prospective employer.
She was given a 30-day licence suspension and fined $3,000.