Manitoba pharmacist suspended after transplant patient went months without medication

A Manitoba pharmacist and pharmacy owner has been suspended after pleading guilty to dozens of misconduct charges, including a case in which a kidney transplant patient went more than two months without anti-rejection medication.In a recently released disciplinary decision, the College of Pharmacists of Manitoba found pharmacy owner and manager Zubair Mohammed guilty of 36 separate charges and sub-charges related to his operation of two Manitoba pharmacies in Winnipeg and Morden.As a result of his actions, Mohammed was suspended for four months, fined $22,000 and ordered to pay $35,000 toward investigation and hearing costs. Following the suspension, Mohammed will be prohibited from serving as a pharmacy manager or preceptor for two years.The charges stemmed from multiple complaints and investigations spanning more than two years. One of the most serious incidents involved a kidney transplant patient who went without anti-rejection medication for more than two months.According to the decision, incorrect contact information for the patient's prescriber was entered into the pharmacy's system, causing refill requests to be sent to the wrong physician. The college found Mohammed failed to identify the gap in the patient's medication therapy or notify the patient and prescriber. As a result, the patient went without two anti-rejection doses. “This necessitated a series of procedures to save the kidney from rejection,” the college wrote.According to the agreed statement of facts, Mohammed also admitted to using pre-mixed methadone doses missed by one patient in the preparation of doses for other patients, a practice he adopted in order to reduce costly waste.In one case, the college says another pharmacist prepared three methadone doses for a patient whose prescription was cancelled later that day. The doses were left in the fridge overnight. The following day, Mohammed reused two of those doses in preparing methadone for two other patients.The college said he had misinterpreted information on the pharmacy label and prepared doses that were significantly stronger than the patients' prescriptions. He then witnessed both patients ingest the methadone.“Mr. Mohammed kept no record of the steps he took or the calculations he performed to modify the pre-measured doses,” reads the decision. “He did not maintain a compounding record of these doses, and he failed to conduct a final verification of the compound and formulation of these doses, in breach of his obligations.” Despite serving a large population of opioid agonist therapy patients, neither Mohammed nor several pharmacists working under him had completed accepted opioid agonist therapy training. In another case involving a terminally ill patient who was prescribed fentanyl lollipops, Mohammed admitted he was unfamiliar with the dosage form and dispensed fentanyl patches instead without consulting the prescriber.“This put the patient at serious risk of harm or overdose,” the decision reads.Investigators heard concerns about staffing levels at the Winnipeg pharmacy after overlapping pharmacist shifts were largely eliminated despite high patient volumes and a large opioid agonist therapy practice.“The Main St. Pharmacy was a chaotic, high-stress work environment, which increased the risk of medication errors and undermined patient safety,” the college wrote.

Manitoba pharmacist suspended after transplant patient went months without medication

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