A pharmacist’s record-keeping came under scrutiny due to an investigation into a colleague who allegedly diverted nearly 11,000 oxycodone tablets
A man with 40 years’ experience as a pharmacist has been found guilty of unsatisfactory professional conduct and professional misconduct.
The NSW Civil and Administrative Tribunal heard that the pharmacist started work at a Central Coast, NSW pharmacy in 2012, and that from 1 January 2017 to 3 September 2018, the practitioner was one of two pharmacists in charge there.
He ordinarily worked two days a week as the sole pharmacist there.
In September 2018, the Pharmaceutical Regulatory Unit inspected the pharmacy, and three days later, it submitted a complaint to the Pharmacy Council of NSW.
Between January 2017 and 2018, it was alleged that during the time the practitioner was one of two pharmacists-in-charge at the store, large numbers of drugs of addiction were “unaccounted for and were possibly lost, stolen or diverted”.
The PRU notification alleged that the large amounts of missing S8s were due to the activities of the other pharmacist, a woman who was also an employee at the store.
During the period 1 January 2017 to 3 September 2018 there was a loss of or possible diversion of more than 10,800 oxycodone tablets, the PRU said, and over 1000 alprazolam.
The periodic inventory of S8s had not been performed between 1 January 2017 and 6 September 2018.
On 24 August 2018, an independent check of S8 stocks by a pharmacist employed by the banner group found that 43 out of 60 S8 stock lines were incorrect in the pharmacy’s electronic drug register.
All S8 script duplicates dispensed between November 2016 and February 2017 were missing.
The interim report said that there were multiple discrepancies in the electronic drug register including duplicate drug entries, invoices entered incorrectly or late, and stock adjustments for no clear reason.
And a box in the pharmacy contained eight prescription pads belonging to a doctor, as well as one pad with no doctor’s name specified.
On 26 September 2018, the Pharmacy Council of NSW initiated a complaint against the pharmacist, following the s150 hearing of his colleague.
It alleged that he had failed to make accurate entries in the S8 register and provided his S8 drug register username and password to another pharmacist.
The pharmacist, who had been first registered to practise the profession in 1971, and had been practising for more than 40 years including as an owner/proprietor, said that the Central Coast pharmacy’s dangerous drug recording transitioned from a paper-based system to an electronic system in around late 2016.
Before the change, he had been in charge of the DD book and performed periodic checks and audits, but after the transition his female colleague had taken over the eDD book.
“He assumed she was conducting appropriate checks in accordance with legislation,” the Tribunal noted.
He had assumed that his colleague was performing the periodic inventories of S8s, having told her at the transition that, “You can enter the drugs and it is your baby from now on”.
When asked why another pharmacist had his password, the practitioner said that his colleague had allocated him the password, as she had the mastercode to the eDD. He did not know how to change the password himself.
When he was shown examples of occasions when S8s were not entered into the register when he was rostered in the pharmacy, he said that he did not have an answer and could not remember.
He said he had asked his colleague whether she was “on top of the S8s,” she had assured him she was.
“I should have had a look myself. I should have been more vigilant,” he admitted.
At a time when he had added 120 x oxycodone 5mg (Endone) to the eDD register without an invoice, he said that he had spotted an incorrect balance and entered the drugs to balance the register.
He said he had texted his colleague to ask if she was aware; she said she was not, and he did not investigate further.
Regarding the blank prescription pads, he said a customer of the pharmacy who was also an anaesthetist had asked him to dispose of them.
He said he had agreed to have them destroyed when next the Council Inspector visited, but as he had missed the last three visits by the inspector, the pads remained at the pharmacy.
“The delegates found his explanation difficult to believe, or in any event, a very irresponsible action given the possibility that the pads could have been used illicitly,” the Tribunal noted.
The pharmacist had also stored Ritalin for Patient A, with whom he lived, at the pharmacy because she had a history of exceeding her prescribed dosage and he was concerned for her safety.
The Ritalin had been correctly dispensed and he accepted he should have stored it more appropriately.
In another instance he stored Targin incorrectly for an elderly patient who used it intermittently. The Targin had been kept for storage in a Webster pack the next week, but was not appropriately stored.
Another packet of Targin for another patient had been brought back for disposal, and the practitioner said he had intended to destroy it, but it had been inappropriately stored in the meantime.
Regarding his colleague, he said that he had believed she was a trustworthy person and a good pharmacist, and had never suspected that she was involved in the diversion of S8 drugs.
The Tribunal heard that he was not suspected in any way of being involved with his colleague’s diversion of the medicines.
The pharmacist expressed contrition and said that if he were able to register again, he would work as a locum on a casual basis.
He has not worked for the last two and a half years in pharmacy.
The Tribunal found that the practitioner was guilty of unsatisfactory professional conduct and professional misconduct.
Had the man still been a registered pharmacist, the Tribunal would have cancelled his registration with immediate effect, it said.
It ordered that he is not permitted to apply for registration again for a year, and told him to pay a third of the Health Care Complaints Commission’s costs.