Workload issues may have led to pharmacy failures


A pharmacy owner has been reprimanded and must practise under “onerous” conditions after more than 10,000 Endone tablets went missing due to an employee’s actions

The pharmacist is the sole proprietor of a pharmacy in western Sydney, as well as a partner in two pharmacies near Newcastle. He was also previously the owner of an eastern Sydney pharmacy, which he sold in March 2018.

In April 2015, a Pharmaceutical Services Unit (PSU) senior pharmaceutical officer attended both Sydney pharmacies. At the western suburbs pharmacy, the PSU officer found that between May 2014 and April 2015, 785 Endone tablets (39 proprietary packs) were unaccounted for.

Meanwhile another 9,260 Endone tablets (463 proprietary packs) were unaccounted for at the eastern Sydney pharmacy between June 2014 and April 2015.

Major deficiencies were identified regarding the practices of the owner’s employed pharmacists at the two locations with respect to the management and administration of S8 medications and their prescriptions.

Added to this were failures to carry out regular mandatory stock checks of S8 medicines, alteration of drug registers, and an inability to account for and notify authorities of discrepancies in stock levels of S8 medicines.

Issues were also identified regarding the dosing of patients on the Opioid Treatment Program (OTP) and the compliant affixing of a safe which contained OTP medications.

The NSW Civil and Administrative Tribunal found the pharmacy owner had abdicated his professional obligations as a proprietor in failing to adequately supervise and oversee the conduct of his employees, and found him guilty of professional misconduct.

It noted that there was no suggestion that the pharmacy owner had misappropriated the missing Endone, and that the employee had also been the subject of disciplinary hearings.

In a recent decision on protective orders, the Tribunal reprimanded the pharmacy owner over the findings.

However it heard that the respondent had undertaken further professional development, sought advice and guidance from an experienced pharmacist (Mr R) and introduced changes in procedure and policy at his pharmacies based on that advice.

Mr R, who has been a registered pharmacist for some 38 years, told the tribunal that while the owner clearly understood the requirements around record keeping of drug registers and was able to take action, his follow up was lacking and he placed too much reliance on his staff to implement changes.

In his evidence about staffing issues within the pharmacy, Mr R noted that current staff pharmacists had been responsible for some of the issues that were the subject of the PRU investigations.

However he believed that these pharmacists were otherwise competent staff and that the issues identified were related more to workload.

Given the view he formed as to the workload in the pharmacy, Mr R suggested to the proprietor that a pharmacy manager be employed full time on an ongoing basis.

On October 2019 the PRU conducted a re-inspection of the western Sydney pharmacy. Its report noted that there was a significant improvement in record keeping, with regular stock check entries observed and no discrepancies with randomly selected drugs of addiction.

They also found positive steps taken including the introduction of a pharmacy manager, reduction of OTP patient numbers, use of variation charts, checklists and other tools have had tangible results in improving regulatory compliance.

A past difficulty identified by the proprietor has been his responsibilities arising from his ownership of multiple pharmacies, impacting ability to spend the time needed in each pharmacy.

He told the tribunal of his intention to sell his Sydney pharmacy, a move he believed would reduce his workload further, giving him more time to fulfil his responsibilities as a proprietor pharmacist. He would maintain his ownership, which he holds in partnership, of the remaining two pharmacies near Newcastle.

According to the Ahpra register, the proprietor is no longer suspended but is registered to practise with conditions, as determined by the tribunal in this decision.

As part of the conditions, he is to undergo mentoring by an experienced pharmacist for a period of 12 months.

He must also submit to audits of his practice, to occur in each pharmacy business in which he has a financial interest. These will be conducted every three months and are to continue for a period of at least 18 months.

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