Pharmacist blames demand for COVID tests on nearly giving patient massive painkiller dose
A pharmacist in Brampton blamed the high demand for asymptotic COVID tests for mistaking morphine for the more powerful hydromorphone after the sister of a patient overheard that a prescription was about to be filled incorrectly.
Dr. Sunitha Kondoor, R.Ph, pharmacist and designated manager at the Great Lakes Drive Shopper's Drug Mart in Brampton, Ontario, was brought in front of the Health Professions Appeal and Review Board on May 11, 2022 to answer for nearly filling a prescription painkiller incorrectly.
The respondent in the case visited the pharmacy with her sister on November 20, 2022, to pick up 30 doses of 5mg of morphine to be taken orally every four hours.
Dr. Kondoor was about to incorrectly fill the order with liquid hydromorphone when the respondent's sister overheard and asked Dr. Kondoor if the order was for hydromorphone or morphine.
Hydromorphine is five to 10 times more potent than morphine.
The review board notes that the respondent said Dr. Kondoor was at first certain that the order was for hydromorphone and not morphine and was “somewhat argumentative.”
During the hearing, Dr. Kondoor stated that the pharmacy was quite busy due to COVID-19 related pre-screening for asymptomatic testing. Further, the respondent seemed to be in pain, so she wanted the respondent to receive her medication as quickly as possible.
After realizing the error, she discovered that the pharmacy didn't have the morphine to fill the respondent's prescription, so she called another pharmacy to confirm their stock. Dr. Kondoor then acknowledged the near miss with the respondent and the respondent's sister, who took up the option to go to the other pharmacy to pick up the order.
In their written decision, the board rejected blaming a hectic COVID-19 screening schedule for the near error:
With respect to the Applicant’s explanation that the pharmacy was busy due to COVID-19 screening, the Committee reminded the Applicant that no matter what type of checking routine is in place, it must always be performed regardless of store volume or staffing level, and that a hectic pace behind the dispensary counter calls for additional diligence when checking and dispensing medications.
As a result, the board issued advice and recommendations to Kondoor, and are requiring her to complete a Specified Continuing Education or Remediation Program (SCERP). One dissenter on the board agreed with the facts and recommendations, but disagreed that Dr. Kondoor ought to complete SCERP.
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