Manitoba pharmacist disciplined after potentially 'fatal' fentanyl error

A Manitoba pharmacist has been fined and ordered to cover the costs of his hearing after a disciplinary panel found him responsible for multiple failures in oversight, including fentanyl dispensing errors and a transplant patient going weeks without medication.Mohamed Fathy Abdelhamid served as pharmacy manager at a Shoppers Drug Mart in Morden, Man. between September 2021 and July 2022, but he stepped down from the position "due to continued chaos in that department," according to a recently published disciplinary decision from the College of Pharmacists of Manitoba. At an October 2025 hearing, Abdelhamid pleaded guilty to professional misconduct, admitting he “displayed a lack of knowledge, skill or judgment” in his job, according to the decision dated Jan. 16. For his actions, Abdelhamid has been ordered to pay a $7,500 fine, as well as an additional $7,500 to cover the cost of investigation and hearing. The college said it opened an investigation into Abdelhamid after a kidney transplant patient complained in 2023, alleging the pharmacy he managed failed to provide a continuous supply of critical immunosuppressant medications for more than two months. The lapse required the patient to receive emergency treatment to prevent rejection, but the transplanted kidney was still permanently damaged, said the panel. In a separate 2022 case, the college found that Abdelhamid did not properly follow up after a different patient received the wrong fentanyl medication.Instead of being prescribed 50-microgram fentanyl lollipops, the patient received patches that release that same dose—per hour. “In a patient who has not gradually developed a tolerance for strong opioids such as fentanyl, the provision of a 50 mcg/hour dose can be dangerous, even fatal,” wrote the panel in its decision. The error went unnoticed for several days, during which the patient used the patches before the mistake was caught. Despite this, the panel found Abdelhamid failed to properly investigate the incident or follow up with staff in a meaningful way. He did not speak with the pharmacy assistant who entered the prescription incorrectly, nor did he examine the root causes behind the error. The patient's family doctor called "looking for clarification on the fentanyl product given to the patient."The panel noted that after that call, “Mr. Abdelhamid did not hold any huddle, meeting or other discussion with pharmacy staff to discuss the incident.” These were not isolated incidents: according to the panel, dozens of prescriptions were dispensed without any record that a pharmacist had counselled the patient—or that the patient had declined counselling. In some cases, more than 100 prescriptions in a single day lacked proper documentation.Investigators also found that pharmacy assistants sometimes handed out medications without involving a pharmacist, even for new prescriptions where counselling is required.Inventory controls for narcotics and other controlled drugs were also inconsistent, according to the panel. Required counts were often incomplete or skipped altogether. And discrepancies—some involving shortages—were rarely investigated or reported.Of 130 discrepancies identified over a roughly nine-month period, only two had any documented follow-up.In its ruling, the panel acknowledged mitigating factors, including Abdelhamid’s relative inexperience as a pharmacy manager and the pressures of working during the COVID-19 pandemic. He had been in the role for less than a year and described a high-stress environment with staffing challenges and limited training. Still, the committee emphasized that those conditions did not excuse the failures.“The responsibilities of the pharmacy manager are clearly laid out,” the panel wrote, noting that Abdelhamid failed to meet those obligations in areas that were within his control.The panel said the outcome was intended to reinforce professional standards and maintain public confidence in the profession’s ability to regulate itself.

Manitoba pharmacist disciplined after potentially 'fatal' fentanyl error

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