File # 20-CRV-0692  
HEALTH PROFESSIONS APPEAL AND REVIEW BOARD  
PRESENT:  
Bonita Thornton, Designated Vice-Chair, Presiding  
Yasmeen Siddiqui, Board Member  
Mitchell Toker, Vice-Chair  
Review held on February 23, 2022 in Ontario (by video-conference)  
IN THE MATTER OF A COMPLAINT REVIEW UNDER SECTION 29(1) of the Health  
Professions Procedural Code, Schedule 2 to the Regulated Health Professions Act, 1991, Statutes  
of Ontario, 1991, c.18, as amended  
B E T W E E N:  
IRSHAD-UL HAQ, R.Ph  
Applicant  
and  
JM  
Respondent  
Appearances:  
For the Applicant:  
Craig Colraine and Olivia Mann-Foster, co-counsel  
DECISION AND REASONS  
I.  
DECISION  
1.  
The Health Professions Appeal and Review Board confirms the Inquiries, Complaints  
and Reports Committee of the Ontario College of Pharmacists to require Irshad-Ul Haq,  
R.Ph to complete a specified continuing education and remedial program, specifically:  
the Designated Manager (DM) e-Learning Module, offered by the College, and the  
Incident Analysis and Proactive Risk Assessment Workshop offered by the Institute for  
Safe Medication Practices Canada, and to participate in remediation follow-up conducted  
by College staff within 24 months following the successful completion of the programs;  
and to advise the Applicant of his obligations under NAPRA [the National Association of  
Pharmacy Regulatory Authorities] Model Standards of Practice and particularly advise  
the Applicant of the following:  
Standard #3 Safety and Quality  
General Standard  
Pharmacists undertake continuing professional development quality and  
assurance and quality improvement  
Model Standard of Practice  
Pharmacists regardless of the role they are fulfilling:  
3. ensure that staff supports personnel for whom they are  
responsible are delegated and undertake pharmacy-related  
activities appropriate to the training and consistent with  
legislation, regulation and policies  
4. ensure that staff or support personnel working under  
their direct supervision competently perform delegated  
pharmacy related activities  
Model Standard of Practice  
Pharmacists when managing a pharmacy:  
7. develop polices and standard operating procedures that  
ensure a safe and effective system of medication supply is  
maintained at all times  
8. develop policies and standard operating procedures that  
support staff’s ability to continuously improve the safety  
and quality of patient care provided  
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9. develop and implement practice change models based on  
measurement improvement in the quality of care and  
services provided by pharmacists  
15. review errors and incidents to determine patterns and  
casual factors that contribute to patient risk  
16. develop and implement policies and procedures that  
minimize errors  
Standard #4 Professionalism and Ethics  
General Standard  
Pharmacists demonstrate professionalism and apply ethical principles in  
the daily work.  
Model Standard of Practice  
Pharmacists, when providing patient care:  
7. Maintain the patient’s best interests as the core of all activities.  
2.  
This decision arises from a request made to the Health Professions Appeal and Review  
Board (the Board) by Irshad-Ul Haq, R.Ph (the Applicant) to review a decision of the  
Inquiries, Complaints and Reports Committee (the Committee) of the Ontario College of  
Pharmacists (the College). The decision concerned a complaint from JM (the  
Respondent) on behalf of her mother (the patient), regarding the conduct and actions of  
Irshad-Ul Haq, R.Ph (the Applicant). The Committee investigated the complaint and  
decided to require the Applicant complete a specified continuing education and remedial  
program (SCERP) and participate in remediation follow-up conducted by College staff,  
and to advise the Applicant of his obligations under NAPRA Model Standards of  
Practice, as set out above.  
3.  
The Board issued a publication ban in this matter. This decision is subject to that order.  
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II.  
BACKGROUND  
4.  
The Respondent is the daughter of the patient. The patient had a fall in August 2019,  
which was attributed to her mismanagement of her medications. Following this incident,  
the patient began receiving her medications in a compliance pack.  
5.  
The Applicant is a pharmacist and the designated manager and owner of Shopper’s Drug  
Mart, Tecumseh Road, Windsor (the Pharmacy) where the patient had her prescriptions  
filled.  
The Complaint and the Response  
The Complaint  
6.  
The Respondent complained that there were three errors with the patient’s compliance  
pack made at the Pharmacy, as follows:  
an error was made with respect to patient’s oxycodone;  
three weeks later zopiclone was put in the patient’s compliance pack after it  
had been discontinued;  
after the patient was taken off paroxetine and started on Trintellix,  
paroxetine remained on the label of the compliance pack on two occasions,  
although there was none in the pack, and the compliance packs contained  
two tablets of Trintellix, when only one tablet per day was prescribed and  
the label indicated one tablet per day.  
The Response  
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7.  
Prior to receiving the College’s “Notice of Complaint”, the Applicant was contacted by  
the Committee investigator on February 3, 2020, who requested the Applicant’s  
assistance, as designated manager, in obtaining records and information regarding a  
“matter that had come to its attention.” The Applicant provided the requested documents,  
along with additional documents during the course of the investigations. The documents  
provided included the following:  
the patient’s prescription;  
prescription hardcopies with all markings;  
patient’s full history;  
cancelled prescriptions or transactions;  
the identities of the staff members who spoke with the patient regarding  
the errors that were the subject of the complaint;  
written policies and procedures;  
prescription transfer documents and reports;  
documented correspondence with the prescriber and the subject  
prescription;  
blister pack information sheets for January 13, 2020 and the blister pack  
schedule for the patient;  
the pharmacy incident report; and  
the Shared Services Agreement with Central Fill.  
8.  
9.  
On August 12, 2020, the Applicant responded to the College’s Notice of Complaint and  
addressed the Respondent’s concerns and provided explanations, including the following.  
The Applicant addressed the first incident and stated that the error related to oxycodone  
and noted that it occurred on December 21, 2018, was identified, and was then corrected  
on February 28, 2019, and that this error occurred prior to the patient starting on blister  
packs on May 12, 2019. The dispensing pharmacist, AA, accepted the error with respect  
to when she dispensed Supeudol 10 mg instead of oxycodone. The Applicant conducted  
an investigation which revealed that AA dispensed the prescription according to the  
information in the patient’s file, however one of her colleagues had faxed the patient’s  
doctor for clarification, and while the fax back from the doctor was scanned into a  
patient’s record, the medication on file did not match the one in the faxed response.  
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10.  
11.  
The Applicant indicated that the standard procedure in place at the Pharmacy was that all  
data entry is completed once a fax is scanned into a patient’s profile, and it would go  
through the universal verification steps, however in the patient’s case the medication  
entered did not match the scanned document.  
The Applicant stated that an action plan was put into place to prevent this type of error in  
the future including:  
all clarifications go to the pharmacist on duty to review before scanning or  
modifying the patient records;  
pharmacist to check for changes in therapy and call patient to inform of  
changes; and  
document counselling.  
12.  
The Applicant indicated that a pharmacist, MR, was involved with the error in the second  
incident, when zopiclone was put in the patient’s compliance pack. He stated that the  
error occurred because changes to the patient’s medication were made after the third of  
three blister packs had been sent to Central Fill, so it did not reflect the updated  
medication. The Applicant stated that there was a procedure in place to update any packs  
where a change in medication is made by the prescriber between the time it is sent to  
Central Fill and the time the pack is received back to the Pharmacy, however the change  
was not made to the [third] pack, although MR did correct this and apologized.  
13.  
The Applicant stated that his action plan to prevent this type of error in future, included:  
an additional mandatory procedure had been added to the standard operating  
procedure, involving the pharmacy assistant checking for changes; and  
the Applicant re-reviewed all procedures with his team, reminded them to  
check all new blister pack prescription for any changes, and to contact  
patients to address those changes; that every change is logged on the blister  
pack changes log sheet; and affected blister packs are pulled, and changes  
made.  
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14.  
The Applicant indicated that in the third incident MR conducted the final product check  
of the blister pack filled on January 13, 2020, following the change where the patient’s  
paroxetine was discontinued and Trintellix was prescribed. MR missed both the label  
change, with the result that there were two tablets of Trintellix in the blister pack, rather  
than the correct dose of one tablet.  
15.  
The Applicant stated that an action plan was put in place to prevent this type of error in  
the future, including:  
he reviewed all procedures with MR;  
an additional mandatory procedure was added with the pharmacy assistant  
making changes to the pack and the pharmacist performing the final check;  
and  
when checked, all packs would be immediately moved to the delivery or  
pick up area and not left in blister packaging area to avoid confusion or  
error.  
16.  
The Applicant stated that as designated manager he took the complaint very seriously and  
as an opportunity for continuous improvement, that he worked to identify the root causes  
and then developed and discussed action plans with his team to avoid errors in the future.  
As well he oversaw training of his team and reinforced procedures. He stated that blister  
pack procedures were well explained and the processes implemented, however there were  
several system failures in the incidents. The Applicant added that “since the incident [he  
was] personally overseeing to ensure the existing and new procedures are being followed.  
[He] also reviewed training procedures and all pharmacists and new hires are required to  
acknowledge that they have read blister pack procedures within 3 months of hire.”  
17.  
The Applicant apologized to the Respondent and the patient and stated that the incident  
had allowed him to apply a continuous improvement lens to the matter to strengthen  
processes and procedures.  
The Committee’s Decision  
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18.  
The Committee investigated the complaint and decided to require the Applicant to  
complete a SCERP and participate in remediation follow-up conducted by College staff,  
and to advise the Applicant of his obligations under NAPRA Model Standards of  
Practice, as set out above.  
19.  
20.  
The Committee considered and noted the Respondent’s three concerns as set out in her  
complaint, and the Applicant’s apology and response to each concern.  
The Committee stated that the pattern and number of errors in the patient’s compliance  
pack reflected system failures. The Committee observed that in the first incident, the  
clarification from the prescriber was scanned as an addendum to the original prescription  
instead of as a new prescription and was not noticed by the dispensing pharmacist. The  
Committee noted that in the second incident, procedures for ensuring that compliance  
packs were corrected to reflect changes made to the patient’s medication after the  
prescriptions were sent to Central Fill, were not followed. The Committee stated that in  
the last incident, the discontinuance of paroxetine and the addition of Trintellix were not  
properly documented or checked. The Committee stated that in each case the Pharmacy’s  
policies and procedures were either inadequate or were not followed properly by staff.  
21.  
The Committee stated that as the designated manager, the Applicant was responsible for  
ensuring that adequate policies and procedures were in place for the Pharmacy for  
accurate dispensing of compliance packs. The Committee added that it was the  
Applicant’s responsibility to ensure that all staff are trained on and consistently adhere to  
the training and supervision of unregulated pharmacy staff. The Committee pointed out  
the designated manager’s role was to promote and encourage a culture of safety in the  
Pharmacy and a commitment to dispensing the right drug in the right dose and strength to  
the right patient.  
22.  
The Committee noted that the Applicant acknowledged that system failures led to the  
incidents in question and that he indicated that he had made changes to prevent similar  
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errors, and that he had discussed the errors made by the pharmacists on staff. The  
Committee stated however that the Applicant’s analysis of the incidents failed to show  
insight into his own responsibilities and role in the errors. The Committee added that the  
Applicant failed to conduct a thorough root cause analysis of the errors and that his action  
plan for improving the Pharmacy’s systems and operations was not robust or  
comprehensive.  
23.  
24.  
The Committee pointed out that patients who receive compliance packaged prescriptions  
rely on the pharmacist to help minimize the risk of patients taking their medications  
improperly and stated that it was incumbent on pharmacy staff to take an extra modicum  
of care when dispensing compliance packaged prescriptions.  
The Committee noted that these dispensing errors reached that patient and added that  
fortunately they were noticed by the Respondent prior to the medication being ingested  
by the patient.  
Disposition of a SCERP  
25.  
The Committee stated that the decision to direct the Applicant to complete a SCERP was  
based on its observation that there was a pattern of dispensing errors reflecting system  
failures in the Pharmacy; that the Applicant failed to conduct a thorough root cause  
analysis of the incidents in question; and that the Applicant failed to show insight into his  
roles and responsibilities as the designated manager of the Pharmacy. The Committee  
was of the opinion that the remediation program would provide the Applicant with the  
tools to analyze weaknesses in the Pharmacy’s practice, identify areas of improvement,  
and implement appropriate changes to prevent future errors.  
Disposition of Advice/Recommendations  
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26.  
The Committee decided that it was reasonable and appropriate in the public interest to  
also issue advice and recommendations. The Committee was of the view that the advice  
and recommendations it provided would assist the Applicant in how he might be more  
thoughtful in his practice when establishing and enforcing the Pharmacy’s policies and  
procedures for safe and accurate dispensing, and also reasonable and appropriate in the  
public interest.  
III.  
REQUEST FOR REVIEW  
27.  
In a letter dated December 9, 2020, the Applicant requested that the Board review the  
Committee’s decision.  
IV.  
POWERS OF THE BOARD  
28.  
After conducting a review of a decision of the Committee, the Board may do one or more  
of the following:  
a) confirm all or part of the Committee’s decision;  
b) make recommendations to the Committee;  
c) require the Committee to exercise any of its powers other than to request a  
Registrar’s investigation.  
29.  
The Board cannot recommend or require the Committee to do things outside its  
jurisdiction, such as make a finding of misconduct or incompetence against the member  
or require the referral of specified allegations to the Discipline Committee that would not,  
if proved, constitute either professional misconduct or incompetence.  
V.  
ANALYSIS AND REASONS  
30.  
Pursuant to section 33(1) of the Health Professions Procedural Code (the Code), being  
Schedule 2 to the Regulated Health Professions Act, 1991, the mandate of the Board in a  
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complaint review is to consider either the adequacy of the Committee’s investigation, the  
reasonableness of its decision, or both.  
31.  
32.  
The Respondent did not attend the Review. The Board notes that there is no legislative  
requirement for parties to attend a review and draws no inference from the Respondent’s  
non-attendance.  
The Board has considered the submissions of the Applicant, examined the Record of  
Investigation (the Record), and reviewed the Committee’s decision.  
Adequacy of the Investigation  
33.  
An adequate investigation does not need to be exhaustive. Rather, the Committee must  
seek to obtain the essential information relevant to making an informed decision  
regarding the issues raised in the complaint.  
34.  
The Committee obtained the following documents:  
the Respondent’s letter of complaint with enclosures and subsequent  
correspondence;  
the Applicant’s information to the Committee sent as designated manager,  
as noted above and including standard operating procedures, shared  
services agreement, and compliance pack agreements from the Pharmacy;  
the Applicant’s letter of response to the complaint and subsequent  
correspondence;  
the patient’s pharmacy records; and  
The NAPRA Model Standards of Practice.  
35.  
36.  
Counsel for the Applicant submitted that the Committee’s investigation was not adequate.  
Counsel for the Applicant submitted that the Committee did not fully explore the “key  
issue” with respect to a designated manager’s responsibilities or explore details regarding  
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the circumstances leading to the dispensing errors. Counsel submitted that the Committee  
investigator did not obtain essential information, resulting in the Committee receiving  
incomplete materials on which to base its decision.  
37.  
Counsel submitted that the Committee should have requested and obtained all the policy  
and procedures documents for the whole operation of the Pharmacy in place at the  
Pharmacy at the time of the alleged error, as well as documentation on the training  
undertaken by the unregulated Pharmacy staff. Counsel submitted that had such  
documentation been requested during the investigation, the Applicant would have  
provided training documents and staff acknowledgments relating to the policies and  
procedures, as well as the Pharmacy standards.  
38.  
Along with his written submissions, Counsel provided the Board with extensive policies  
and other documentation in support of his submissions, including copies of:  
acknowledgment guidelines;  
notes and policies relevant to dispensing of prescriptions in the Pharmacy  
and to training of staff;  
“Pharmacy 2020 standard operating procedures (SOPs) and Protocols  
Annual Sign-Off Tracker”; and  
additional notes and policies relevant to dispensing of prescriptions in the  
Pharmacy and to training of staff.  
39.  
Counsel submitted that the Committee did not put the Applicant on notice that the  
existence or adequacy of Pharmacy policies and procedures, including training and  
documentation of regulated employees, was a concern.  
40.  
41.  
The Board finds that the Committee conducted an adequate investigation.  
The Board notes that in a letter dated February 3, 2020, the Committee asked the  
Applicant for information that included pharmacy records and information related to the  
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dispensing of medication to the patient, including the Pharmacy incident report and any  
notes or screen shots on file for the patient’s listed prescriptions. The Committee  
requested the names of Pharmacy staff who spoke with the patient or her agent regarding  
the three dispensing incidents; any prescription transfer documents/reports for the patient;  
all documentation of correspondence with the prescriber for this patient and listed  
prescriptions; and all blister pack information sheets. In addition, the Committee  
requested information on specific policies:  
Written procedures/policies followed by the Pharmacy for the following:  
• Blister pack procedures, including:  
o starting a new patient on compliance packaging;  
o determining the frequency of dispensing for a compliance  
package;  
o central fill/shared services agreements, if applicable; and  
o disclosures related to a breach of confidentiality  
• Responding to medication errors  
42.  
The Board also notes that the Applicant was notified of the complaint in a letter from the  
Committee, dated July 14, 2020 and his response was requested. The Committee’s letter  
identified the concerns raised by the Respondent regarding the dispensing errors at the  
Pharmacy, and the Committee stated that the complaint was filed against the Applicant in  
his capacity as designated manager. The Committee noted that “as Designated Manager  
of the Pharmacy, you are responsible for the supervision and training of both professional  
and lay staff.” In a follow up letter from the Committee, the Applicant was provided with  
additional information that had been obtained by the Committee and the Applicant was  
asked to provide any updated version of the Pharmacy’s standard operating procedures  
and any other updated Pharmacy policies and procedures.  
43.  
The Board notes that in his response to the Committee, the Applicant referred to his  
oversight as designated manager, referred to conducting initial and ongoing training and  
of reinforcing procedures, and described the Pharmacy’s standard procedures and the  
action plans he put in place to “prevent these types of errors in future.”  
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44.  
45.  
The Board finds that when seeking the Applicant’s response, the Committee asked the  
Applicant to submit relevant policy and procedure documents and drew the Applicant’s  
attention to his role as a designated manager in training staff.  
The Board finds that the Committee therefore provided the Applicant with notice that the  
relevant policies and procedures, including training, were being considered by the  
Committee. The Board finds that the Committee did not need to make additional requests  
for policy and training documents or require all the policy and procedure documents for  
the Pharmacy, as submitted by Counsel, in order to conduct an adequate investigation.  
46.  
47.  
The Board notes that the Committee obtained the Applicant’s response, detailed  
information about the Pharmacy provided by the Applicant in his role as Designated  
Manager, and the patient’s pharmacy records. The parties were offered the opportunity to  
submit information to the Committee and both parties took that opportunity.  
The Board finds the Committee’s investigation covered the events in question, and that it  
obtained relevant information to make an informed decision regarding the issues raised in  
the complaint. There is no indication of further information that might reasonably be  
expected to have affected the decision, should the Committee have acquired it.  
Accordingly, the Board finds that the Committee’s investigation was adequate.  
Reasonableness of the Decision  
48.  
In determining the reasonableness of the Committee’s decision, the question for the  
Board is not whether it would arrive at the same decision as the Committee. Rather, the  
Board considers the outcome of the Committee’s decision in light of the underlying  
rationale for the decision, to ensure that the decision as a whole is transparent, intelligible  
and justified. That is, in considering whether a decision is reasonable, the Board is  
concerned with both the outcome of the decision and the reasoning process that led to  
that outcome. It considers whether the Committee based its decision on a chain of  
14  
analysis that is coherent and rational and is justified in relation to the relevant facts and  
the laws applicable to the decision-making process.  
49.  
50.  
51.  
Counsel for the Applicant submitted that the Committee’s decision was not reasonable.  
Counsel made extensive written and oral submissions, summarized as follows.  
Counsel submitted that the decision was unreasonable, and the Committee’s findings  
were not supported by the Record.  
Counsel noted that the Applicant did not make the errors that were the subject of the  
complaint, but the Committee focused on these errors, and concluded that the errors  
formed a pattern. Counsel submitted that each of the three incidents were separate and  
unique, not traced back to the same issue, and should be analyzed on an individual basis.  
Counsel submitted that the classification of these errors as a “pattern” was an  
unsupportable inference, did not follow a coherent chain of analysis and was not a  
rational finding.  
52.  
The Board finds that the Committee’s reference to the three incidents as a pattern, does  
not render the decision unreasonable. The Board notes that in its decision, the Committee  
identified that the information in the Record showed that all three errors related to  
medication dispensed at the same pharmacy, by way of compliance packs for the same  
patient, and over a relatively short period of time.  
53.  
Counsel for the Applicant submitted that the Committee conducted no analysis of the  
issue of whether the Applicant, as designated manager, instituted sufficient policies, but  
instead focused on the errors. Counsel noted that the Committee stated that in each  
instance [of the errors], the Pharmacy’s policies and procedures were either inadequate or  
were not followed properly by staff. Counsel submitted that the Committee conflated the  
issues and reached unsupported inferences and findings.  
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54.  
The Board finds that the Committee’s decision demonstrates a rational and coherent  
chain of analysis. The Committee considered the three compliance-pack dispensing errors  
that occurred and also considered whether the Applicant, as designated manger, had  
adequate policies, procedures and training in place with respect to compliance packs. The  
Board finds that the Committee decision reflects that the Committee identified the errors  
that occurred, and the Committee also considered and commented on the relevant policies  
provided by the Applicant, and the subsequent changes instituted by the Applicant  
following the incidents.  
55.  
Counsel submitted that the Committee’s conclusion was “untenable” and was not  
supported or based on the materials in the Record. Counsel submitted that there was no  
information to support the Committee’s finding “that policies and procedures to prevent  
the alleged errors from occurring were not in place.” Counsel submitted that it was clear  
from the documents in the Record, along with the additional documents provided to the  
Board, that the Pharmacy had instituted various policies, protocols, guidelines, checklists  
and training aimed at preventing the incidents of dispensing errors.  
56.  
Counsel further submitted that the Committee failed to identify any system errors or to  
connect the dispensing errors to these system errors, failed to identify any gaps in the  
policies and procedures that resulted in the errors, and failed to identify how the policies  
and training implemented by the Applicant were inadequate. Counsel submitted that the  
Committee also did not identify any standard practice, as set out in the Model Standards  
of Practice for Canadian Pharmacists, with which the Applicant did not comply.  
57.  
The Board finds that the Committee’s decision is supported by information in the Record.  
As noted above, this included the following: information about the three errors; the  
patient’s prescription history; the blister pack information sheets; polices and procedure  
information provided by the Applicant with respect to dispensing compliance packs; and  
the Applicant’s information about his action plans, which included the changes he made  
to prevent similar errors, and staff training on those changes.  
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58.  
59.  
The Board notes that the circumstances of this complaint required the Committee, which  
included three professional members, to rely on its knowledge and expertise related to the  
expected standards of the profession in assessing the Applicant’s conduct and actions.  
The Board finds that the Committee, in reviewing the information in the Record,  
reasonably relied on its knowledge of the profession, including the safety and quality  
standards of practice and the standards for a managing pharmacist. The Board notes that  
the Committee identified it had concerns with the Applicant’s analysis of the errors and  
had concerns regarding the Pharmacy’s systems and with the Applicant’s action plans,  
instituted following the dispensing errors. The Committee concluded that these were not  
sufficiently robust or comprehensive. The Board observes that the Committee referred to  
the specific NAPRA standards which would provide the Applicant with the tools for  
improving his practice and the Pharmacy’s systems. The Board finds that the Committee  
identified its concerns with the processes implemented by the Applicant and identified  
the relevant standards.  
60.  
Counsel for the Applicant made submission with respect to the Committee’s disposition  
of a SCERP, and advice and recommendations to the Applicant. Counsel submitted that it  
was noteworthy that neither of the two pharmacists involved with the errors had a  
discipline history with the College and that, while they were investigated due to the  
incidents, neither received advice or any requirements for further education from the  
College. Counsel submitted it was difficult to conceptualize how those outcomes were  
appropriate when the Applicant was not directly involved with the errors. Counsel also  
noted that the Applicant had no conduct history.  
61.  
62.  
The Board finds that the Committee’s disposition is reasonable.  
The Board finds that the Committee was not required to consider any decision or  
disposition that might have been reached with respect to the dispensing pharmacists  
involved with the errors. The Board notes that there is an array of dispositions available  
to the Committee, all of which can be characterized as remedial in nature. The Committee  
has the discretion to choose the appropriate outcome, provided there is a coherent and  
rational line of analysis flowing from the information in the Record to the disposition.  
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63.  
The Board observes that in assessing the appropriate disposition in a complaint, a  
committee will consider many factors, including the seriousness of the deficiency,  
whether there is a single concern or a number of concerns about the care at issue, the  
content of a member’s response, his or her insight as to areas for improvement, along  
with the member’s complaints or discipline history.  
64.  
The Board notes, as mentioned above, that the Committee set out its rationale for  
requiring these remedial and educational steps. The Committee referred to the potential  
risk the errors had posed, and it noted that in the Applicant’s response he had indicated  
that he had made changes to prevent similar errors. The Committee considered that that  
the Applicant as designated manager was responsible for ensuring the Pharmacy had  
sufficient polices in place to ensure the safe and accurate dispensing of medication and  
the Committee determined that the Applicant had not shown sufficient insight into the  
errors and had failed to conduct a thorough root cause analysis of the incidents. The  
Board notes that the Committee indicated that the education program would provide the  
Applicant with the tools to analyze weaknesses in the Pharmacy’s practice, and identify  
areas of improvement, and implement appropriate changes to prevent future errors.  
65.  
The Board observes that the Committee also provided its rationale for the additional  
disposition of providing advice to the Applicant of his specific obligations under the  
NAPRA model. The Committee stated that these would assist the Applicant in how he  
might be more thoughtful in his practice when establishing and enforcing the Pharmacy’s  
policies and procedures for safe and accurate dispensing.  
66.  
The Board finds that the Committee identified its concerns, relied on its knowledge of the  
expected standards of the profession, and provided a coherent and rational chain of  
analysis in its decision. The Board therefore finds that the Committee’s decision to  
require the Applicant complete the DM e-Learning Module and the Incident Analysis and  
Proactive Risk Assessment Workshop and to advise the Applicant on NAPRA standards is  
reasonable.  
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Conclusion  
67.  
The Board finds that the Committee conducted an adequate investigation and reached a  
reasonable decision. The Committee’s decision addresses the concerns raised in the  
complaint, is based on the information in the Record, and demonstrates a coherent and  
rational connection between the relevant facts, the outcome of the decision and the  
reasoning process that led it to that outcome. The Committee’s decision as a whole is  
transparent, intelligible, and justified.  
VI.  
DECISION  
68.  
Pursuant to section 35(1) of the Code, the Board confirms the Committee’s decision to  
require the Applicant complete a specified continuing education and remedial program,  
specifically: the Designated Manager (DM) e-Learning Module, offered by the College,  
and the Incident Analysis and Proactive Risk Assessment Workshop offered by the  
Institute for Safe Medication Practices Canada, and to participate in remediation follow-  
up conducted by College staff within 24 months following the successful completion of  
the programs; and to advise the Applicant of his obligations under NAPRA Model  
Standards of Practice and particularly advise the Applicant of the following:  
Standard #3 Safety and Quality  
General Standard  
Pharmacists undertake continuing professional development quality and  
assurance and quality improvement  
Model Standard of Practice  
Pharmacists regardless of the role they are fulfilling:  
3. ensure that staff supports personnel for whom they are  
responsible are delegated and undertake pharmacy-related  
activities appropriate to the training and consistent with  
legislation, regulation and policies  
4. ensure that staff or support personnel working under  
their direct supervision competently perform delegated  
pharmacy related activities  
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Model Standard of Practice  
Pharmacists when managing a pharmacy:  
7. develop polices and standard operating procedures that  
ensure a safe and effective system of medication supply is  
maintained at all times  
8. develop policies and standard operating procedures that  
support staff’s ability to continuously improve the safety  
and quality of patient care provided  
9. develop and implement practice change models based on  
measurement improvement in the quality of care and  
services provided by pharmacists  
15. review errors and incidents to determine patterns and  
casual factors that contribute to patient risk  
16. develop and implement policies and procedures that  
minimize errors,  
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Standard #4 Professionalism and Ethics  
General Standard  
Pharmacists demonstrate professionalism and apply ethical principles in  
the daily work.  
Model Standard of Practice  
Pharmacists, when providing patient care:  
7. Maintain the patient’s best interests as the core of all activities.  
ISSUED July 6, 2022  
_Bonita Thornton___  
Bonita Thornton  
_Yasmeen Siddiqui___  
Yasmeen Siddiqui  
_Mitchell Toker_____  
Mitchell Toker  
Cette décision est aussi disponible en français. Pour obtenir la version de la décision en français, veuillez contacter  
[email protected]  
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