Health Professions Review Board

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Victoria British Columbia
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DECISION NO. 2014-HPA-106(a); 2014-HPA-107(a); 2014-HPA-108(a)
(Grouped File: 2014-HPA-G22)
In the matter of an application under section 50.6 of the Health Professions Act,
R.S.B.C. 1996, c. 183, as amended, (the “Act”) for review of a complaint disposition
made by an Inquiry Committee
BETWEEN:

The Complainant

COMPLAINANT

AND:

The College of Pharmacists of BC

AND:

A Pharmacist

REGISTRANT 1

AND:

A Pharmacist

REGISTRANT 2

AND:

A Pharmacist

REGISTRANT 3

COLLEGE

Collectively “the Registrants”
BEFORE:

Marilyn Clark, Panel Chair

DATE:

Conducted by way of written submissions concluding on
September 23, 2015

APPEARING: For the Complainant:

I

REVIEW BOARD

self-represented

For the College

Esther Jeon, Complaints Resolution Office

For Registrant 1:

self-represented

For Registrant 2:

self-represented

For Registrant 3:

self-represented

DECISION

[1]
Upon review of this file at the stage 1 hearing, I was unable to confirm under s.
50.6(8)(a) of the Act whether the investigation had been adequate and the disposition
reasonable. I therefore requested submissions from the College and each of the
Registrants at the stage 2 hearing of this matter. For the reasons that follow I have
determined that the investigation was adequate and that the disposition falls within a
range of rational outcomes.

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II

INTRODUCTION

[2]
The Complainant filed a complaint against three Pharmacists, the Registrants,
following the death of his mother [the “Deceased”] after a fatal drug-drug interaction.
[3]
Following an investigation, the Inquiry Committee decided to take action under s.
36(1) of the Act, which allows the Inquiry Committee to request that a registrant consent
to educational courses, a reprimand and/or any other action specified by the Inquiry
Committee. This resulted in Registrants 2 and 3 each accepting a 30 day suspension of
practice, a requirement for additional educational courses, preparation of papers relating
to the impact of not being attentive to drug interactions, public announcement of their
suspension on the College's website and subsequent audits of their practice.
[4]
Registrant 1, the pharmacy manager, was required to ensure a Pharmacy Policy
was implemented at his pharmacy and that staff received training on assessing drugrelated problems. He also agreed to a practice audit at the pharmacy.
[5]
It is the Complainant's submission that Registrant 2 was negligent in not noting
and following-up on the Level 2 warning that appeared on the pharmacy software
identifying the danger of a drug-drug interaction when he filled a prescription for
Allopurinol on June 29, 2012. This caused an interaction with an existing drug,
Mercaptopurine.
[6]
Further, it is the Complainant's submission that Registrant 3 was negligent when
he processed a renewal for Mercaptopurine on July 9, 2012, without following-up on the
Level 2 warning that once again indicated the possible interaction with Allopurinal.
[7]
The Complainant is seeking more serious consequences for Registrants 2 and 3
who in his words "contributed to the premature, tortuous death of my mother".
III

HISTORY

[8]
The Deceased was an active, independent 76 year old. She suffered from a
number of conditions including ulcerative colitis for which she was prescribed
Mercaptopurine, chronic kidney disease, chronic obstructive lung disease, congestive
heart failure and hypertension. She had been prescribed 12 medications in total.
[9]
On June 29, 2012, she visited her family doctor as a result of pain in her feet. She
was diagnosed with gout and prescribed Allopurinal.
[10] She joined her family on a camping trip for the last week of July and first week of
August and began to experience unusual symptoms. When she returned from the
vacation, she developed a blister on her foot and visited a locum physician who was
concerned she had developed a bacterial infection. Blood tests were performed, the
results of which were troubling, and she was transported to hospital.

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[11] In the Emergency Department at the regional hospital, a physician reviewed her
list of medications and quickly identified the Allopurinal and Mercaptopurine combination
as the culprits advising the family "this should never have occurred, it was 100%
preventable". A diagnosis of pancytopenia was quickly arrived at.
[12] The Deceased was treated with multiple blood transfusions but developed sepsis
and respiratory failure, deteriorating quickly until her death on September 3, 2012. The
coroner declared the death accidental.
IV

DISCUSSION AND BACKGROUND

A.

Registrant 1

[13] Registrant 1, the Pharmacy Manager, was asked to explain the processes in place
in his pharmacy with respect to the dispensing of medications and the documentation of
interactions between drugs.
[14] Registrant 1 explained "that it is standard practice for the pharmacist on duty to
review the local and PharmaNet profiles for all new and refill prescriptions, as required by
law, in order to identify and resolve any potential drug-related problems". He further
explained the Level 1, 2 and 3 warnings that appear as a result of the PharmaNet
software and how frequently such warnings appear. According to Registrant 1, "these
interactions sometimes warrant discussions with the prescriber and the patient, which
may result in monitoring of some sort, or a change to the prescribed treatment".
Sometimes, level 2 warnings may be minor. He described that the practice at his
pharmacy was for the pharmacist to write details of any communication on the
prescription hard copy and to enter a note on the patient's screen.
[15] In the case of the Deceased, Registrants 2 and 3 did not write any details of any
communication on the hard copies and there were no entries on the patient’s screen.
Registrant 1 suggested that during busy times the pharmacists might overlook a warning
and he concludes that is what happened in this case.
[16] In its review, the Inquiry Committee noted Registrant 1's comment, "being human
in a busy retail setting, there are times when an interaction warning could get overlooked,
and this appears to be what happened in this case. . ."
[17]

In her report to the Inquiry Committee, the Complaints Resolution Officer stated:
[Registrant 1's] comment that "being human in a busy retail setting, there are times when
an interaction warning could get overlooked, and this appears to be what happened in this
case" . . . is an unacceptable excuse for "overlooking" a potential drug interaction. In fact,
there is no good excuse for overlooking such an important aspect of pharmacy practice,
busy or not.

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B.

Registrant 2

[18] Registrant 2 originally filled the prescription for Allopurinal on June 29, 2012. In
response to the Inquiry Committee's request for a statement describing his recollection of
filling the prescription and any discussions that occurred with the Deceased, Registrant 2
did not recall that fill but confirmed that he had indeed filled the Allopurinal prescription
and described his customary practice as follows:
To discuss why each medication was prescribed, how to take it, how long it will take to
become effective and the commonly expected adverse effects a patient is likely to
experience. Therefore I can say I believe that I would have followed this standard of care.
In addition, as a matter of standard practice, I would counsel patients regarding any other
concerns such as drug-drug interactions if I was aware that circumstances warranted
such a discussion.

[19] Registrant 2 went on to say that he would have likely noted the low dose of
Allopurinol and the short duration of therapy and therefore it was unlikely he would have
counselled the Deceased about its use.
[20] The response of the Inquiry Committee is clear that the appropriate action for
Registrant 2, after noting the drug-drug interaction, would have been to have a
discussion with the prescribing physician about modifying the therapy by reducing the
Mercaptopurine to 25% of the normal dose and then monitoring for toxic effects. The
combination is not necessarily contraindicated but "modification to the therapy is
recommended for managing the drug-drug interaction".
[21] It is not possible to know whether a modification to the drug therapy would have
been successful for the Deceased. It would not have been comforting to the Complainant
to learn that a different approach might mean his mother would have survived.
[22] Registrant 2 went on in his response to describe the measures implemented at the
pharmacy to ensure there was no recurrence, including advising the prescribing
physician of level 2 interactions. He also indicated they had marked Allopurinol in the
pharmacy as being contraindicated for a patient prescribed Mercaptopurine. As stated in
paragraph [20] above, as therapy modification is the recommended approach, the advice
posted in the pharmacy ought to be altered.
C.

Registrant 3

[23] Registrant 3 dispensed the refill of Mercaptopurine to the Deceased on July 9,
2012. In response to the College's request for information, Registrant 3 wrote:
On Monday, July 9/12 I, [Registrant 3], refilled a prescription for purinethol for [the
Deceased]. As per professional standards her pharmacare profile was reviewed. A level 2
interaction, would have been noted but nothing on the hard copy would indicate we asked
how the patient was feeling. [The Deceased] usually got her prescriptions herself and I

 DECISION NO. 2014-HPA-106(a); 2014-HPA-107(a); 2014-HPA-108(a)
Page 5
believe she was in the store that day. [Registrant 2] checked the physical prescription
preparation and it was given to [the Deceased].

[24]

This is the extent of the response from Registrant 3.

[25] In fact, the renewal of the prescription for Mercaptopurine (purinethol) provided the
pharmacy with a second opportunity to have a discussion with the dispensing physician
about the drug-drug interaction. This opportunity was not taken.
[26] Registrant 2 and 3 each neglected to take action when a drug-drug interaction was
noted on the PharmaNet screen leading to the death of the Deceased.
V

ANALYSIS

[27] The Review Board is limited by the Act to reviewing the disposition and
determining whether the investigation was adequate and the disposition reasonable.
Upon reviewing the disposition, I may confirm the disposition, direct the Inquiry
Committee to make a disposition that was within their mandate or return it for
reconsideration. I cannot change the disposition to one that I or the Complainant might
have preferred. To be clear, if I find the investigation was adequate given the
circumstances and the disposition falls within a range of reasonable outcomes, then I
must confirm the decision of the Inquiry Committee.
A.

ADEQUACY OF THE INVESTIGATION

[28] The College, upon receipt of the complaint on May 22, 2013, contacted Registrant
1, the Pharmacy Manager, requesting the names of the pharmacists who were involved
in the dispensing of the drugs to the Deceased. Each of the Registrants, including the
Pharmacy Manager, was asked to provide written statements. All of the communication
appears to have been by letter and by email. There were no individual interviews.
[29] In that regard, the Complaints Resolution Officer has stated that Registrants 2 and
3 admitted in their statements they had dispensed the drugs and had missed the drug
interactions, so there was no issue of credibility.
[30] The investigator engaged by the College provided a report based on the
statements provided by the Registrants. In addition, the Inquiry Committee had for
review:
(a)

the complaint filed by the Complainant which provided a thorough overview
of the events leading up to his mother's death;

(b)

the Coroner's report;

(c)

the report from the College investigator;

(d)

the Deceased's PharmaNet records;

(e)

the Pharmacy's prescription records for the Deceased;

 DECISION NO. 2014-HPA-106(a); 2014-HPA-107(a); 2014-HPA-108(a)
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(f)

the Professional Practice Policy; and

(g)

on-line documentation on Mercaptopurine's interaction monograph.

[31] Although the Complainant was not interviewed during the course of the
investigation, he had provided the thorough history in his complaint and responded in
detail to the Inquiry Committee decision dated December 11, 2013. That response
prompted another review by the Inquiry Committee in which they responded to the points
made by the Complainant in their second disposition dated March 20, 2014.
[32] The Review Board articulated in Review Board Decision No. 2009-HPA-0001(a) to
0004(a) at paragraph [97] the extent to which a College must investigate a complaint:
A complainant is not entitled to a perfect investigation, but he or she is entitled to
adequate investigation. Whether an investigation is adequate will depend on the facts. An
investigation does not need to have been exhaustive in order to be adequate, provided
that reasonable steps were taken to obtain the key information that would have affected
the inquiry committee’s assessment of the complaint.

[33] The Complainant argues that the investigation was based on email interactions
and at no time were the Registrants interviewed in person. He believes that had the
investigation begun as soon as it was apparent that the drug-drug interaction was the
cause of the Deceased's condition and been conducted in person, there might have been
an opportunity to interview the Deceased prior to her death. The Registrants were
unaware of any reporting requirement; apparently neither was the family physician who
prescribed the drugs nor the emergency room physician who identified the cause of the
Deceased's illness.
[34] The investigation which did not begin until the complaint was filed was surely not
perfect. In-person interviews with the Registrants in their work location may have given a
perspective that is not available through email communication. However, given the facts
of the case, it is my view that the investigation can be considered adequate.
B.

REASONABLENESS OF THE DISPOSITION

[35] The Panel Chair in Review Board Decision No. 2014-HPA-071(a) to 073(a), at
paragraphs [12] and [13], described the task of the Review Board, when considering
whether a disposition was reasonable and the test for determining reasonableness, as
follows:
[12]
The legislature’s reference to the “reasonableness of the disposition” makes clear
that the Review Board is not to ignore what the Inquiry Committee has done or to step into
its shoes. On the other hand, by conferring the review mandate on a specialized Review
Board rather than a generalist court as it could have done, the legislature must equally
have recognized first that it is for the Review Board to determine the degree of deference
that is appropriate in particular circumstances, and second that reasonableness is not
self-applying; the Review Board is not a court and the application of the reasonableness
test will necessarily reflect the Review Board’s specialized role and expertise. The

 DECISION NO. 2014-HPA-106(a); 2014-HPA-107(a); 2014-HPA-108(a)
Page 7
legislature has made clear that it falls within the Review Board’s exclusive jurisdiction to
define and apply “reasonableness” within the context of reforms whose purpose is to
ensure an appropriate degree of college accountability, section 50.63(1).
[13]
The test the Review Board has traditionally applied to determine reasonableness
is whether the Inquiry Committee’s disposition “falls within the range of acceptable and
rational solutions, and is, viewed in the context of the whole record, sufficiently justified,
transparent and intelligible to be sustained.” I see no basis to depart from this view. I
only note that the “range of acceptable and rational solutions” and what is “sufficient”
justification, transparency and intelligibility in a particular case is a question to be
determined by the Review Board on a case by case basis, applying its expertise and
specialized role in good faith, and not simply by comparison to how a generalist court
might apply the test on judicial review.

[36] The Inquiry Committee pursued the course of action outlined in s. 33(6)(c), which
allows the Inquiry Committee to “act under section 36”. Section 36(1), in turn, states as
follows:
(1) In relation to a matter investigated under section 33, the inquiry committee may
request in writing that the registrant do one or more of the following:
(a) undertake not to repeat the conduct to which the matter relates;
(b) undertake to take educational courses specified by the inquiry
committee;
(c) consent to a reprimand;
(d) undertake or consent to any other action specified by the inquiry
committee.
[37] The Inquiry Committee found that this case cast light on a number of practice
deficiencies and was critical of all three Registrants. Neither Registrant 2 or Registrant 3
acted on the drug-related problem even after the level 2 interaction was highlighted on
the PharmaNet screen upon originally filling the Allopurinal prescription and then when
refilling the Mercaptopurine a few days later. Accordingly, the Inquiry Committee
determined that both Registrants had breached the appropriate regulatory standard of
care.
[38] This particular drug-drug interaction is well documented. This information was
available to the Registrants as every pharmacy is required to have at least one
authorized library reference in the Drug Interactions category, in addition to the
PharmaNet alert.
[39] The three Registrants were each asked and agreed to consent to a number of
undertakings with a goal of preventing such errors in the future, including in the case of
Registrants 2 and 3:

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(a) requiring them to follow identified steps for all prescription dispenses, including
refills;
(b) consent to a temporary suspension from practice for a period of thirty days;
(c) complete specified courses available through the Faculty of Pharmaceutical
Sciences at UBC with reinstatement to practice being conditional on the
courses being completed;
(d) provide a written summary to the Complaints Resolution Officer of what they
learned in those UBC courses, such summary to be not less than two pages
and include how they would alter their practice as a result of this incident and
their recent course work;
(e) provide a case summary of a journal article on managing drug-drug
interactions for immunosuppressants; and
(f) upon reinstatement, they would be subject to a practice audit.
[40] The Inquiry Committee reminded Registrant 1, the Pharmacy Manager, of his duty
to ensure a quality management program, as required in section 10 of the Pharmacy
Operations and Drug Scheduling Act (PODSA):
(a) maintains and enforces policies and procedures to comply with all legislation
applicable to the operation of a community pharmacy,
(b) monitors staff performance, equipment, facilities and adherence to the
Community Pharmacy Standards of Practice, and
(c) includes a process for reporting, documenting and following up on known,
alleged and suspected errors, incidents and discrepancies.
[41] Accordingly, Registrant 1 was required to "implement a pharmacy policy relating to
the practice issues and deficiencies raised in this complaint, conduct an educational
training [sic] for his staff and to comply with a practice audit at his pharmacy".
[42]

Further, the Inquiry Committee noted:
There is no excuse for overlooking any DRP (Drug Related Problem) as managing drug
interactions is an important aspect of pharmacy practice. Regardless of staffing levels, the
pharmacy manager is vested with the responsibility of ensuring that registrant and
pharmacy assistant staff levels are commensurate with the workload volume and patient
care requirements at all times.

[43] The Inquiry Committee did not treat this lightly. While it did not issue a formal
citation, it requested, and Registrant 2 and Registrant 3 accepted, serious
consequences, including suspension for 30 days and further education specific to the
issue of drug therapies for each of them. It is evident that, had these consequences not
been accepted, a citation and formal discipline proceedings would have followed.

 DECISION NO. 2014-HPA-106(a); 2014-HPA-107(a); 2014-HPA-108(a)
Page 9
[44]

The Complainant is critical of the disposition in the following areas:
1.
Allowing the Registrants to consent to their punishment in a consent agreement:
this in the eyes of the Complainant allows them to consent or not. In fact, without consent,
they would not have been able to continue to practice.
2.

He suggests that drug-drug interactions always be reported and investigated.

[45] The Coroner's Report identified the death as accidental and noted the deceased
died "of sepsis and respiratory failure due to pancytopenia as a result of drug interaction
between Mercaptopurine and Allopurinal. Congestive heart failure, chronic renal failure,
chronic obstructive lung disease and hypertension were contributory factors".
TUNING DOWN THE SYSTEM
[46] One of the issues the Complainant brought forward was the statement the
prescribing physician wrote in a letter to his College, the College of Physicians and
Surgeons of BC, that "The community pharmacist informed me that because there are so
many potential interactions between medications, they have to tune down their system
not to flag less common or less troublesome interactions."
[47]

Registrant 1, in responding to this allegation, wrote:
The software system we use (Kroll Windows) has never been altered or manipulated in
any way with regards to the displaying of drug interaction warnings. In fact, until I read
[the family physician's] comments, I had never even heard of such a practice. Since we
rely on these drug interaction software programs every day, I cannot imagine a
pharmacist intentionally altering them, or "tuning them down" in order to reduce warning
messages.

[48] The College contacted Kroll directly to determine if manipulation of the software
alert system is possible. Kroll confirmed that their program does not allow manipulation of
alerts at the store level.
[49] Registrants 2 and 3 vehemently denied advising the family physician that they
"tuned the system down" but Registrant 3 did recall having a conversation with the family
physician who called him from the hospital on a weekend enquiring about his
understanding that some alerts had been turned off. Registrant 3 advised the physician
that some background programs, like on-hand quantity and a list of all generics for a
drug, had been turned off as they slowed down the computer and were unnecessary in
their pharmacy. The family physician was satisfied with the explanation, especially when
he learned that the drug-drug interaction warning was on the Deceased's computer
printouts for her prescriptions.
EFFECT OF EVENTS ON REGISTRANTS
[50]

The Registrants have indicated their sorrow and regret over the outcome of this

 DECISION NO. 2014-HPA-106(a); 2014-HPA-107(a); 2014-HPA-108(a)
Page 10
event, the death of the Complainant's mother. The life paths of both Registrants 2 and 3
have been altered.
[51] Registrant 2, in his June 29th response to the Complainant's April 21, 2015,
Statement of Points, writes:
The fallout from this matter has been very damaging personally.
I have been under the care of a psychologist and on antidepressants since I was made
aware of it. Furthermore in October, of 2014, I reached a suicidal state due to ongoing
depression brought about by this incident, and was hospitalized in [nearby City] for
several days on suicide watch. . . Furthermore, as of September 25, 2014, I voluntarily left
practice and have remained inactive as I attempt to overcome my depression.

[52]

Registrant 3 has moved to another jurisdiction and has applied for licensing there.

[53] Clearly, Registrants 2 and 3 have not only been disciplined by the College but
continue to live with their own demons resulting from this event.
CONTINUING EDUCATION REQUIREMENTS
[54] I noted Registrant 2's summary of learnings from the courses he was required to
attend as a result of the undertakings he and Registrant 3 had to fulfill as a part of their
discipline. In that summary he frequently commented on how the world of research had
changed since his graduation some 25 years previously. In particular, he commented on
the value of internet search techniques he had newly learned.
[55] The College requires registrants to complete a minimum of 15 hours of
professional development on a minimum of "6 learning records" every year. This is
mandatory and must be submitted annually upon a registrant's registration renewal.
[56] The College Member profiles included in the Record do not disclose the fulfilment
of the Registrants' annual continuing education. This is a concern for a number of
reasons: ensuring that registrants fulfil the continuing education requirement; ensuring
that the College's registration renewal process is thorough; and a concern throughout this
review about the oversight and management provided the Registrants by the Pharmacy
Manager, including guiding the continuing education needs of the individuals.
VI

CONCLUSION

[57] The Complainant has suffered a loss in the death of his mother and has doggedly
sought justice, whatever that looks like. It appears to me that for the Complainant, justice
means severe discipline be assigned Registrant 2 and Registrant 3 and a formal process
of reporting be established for all missed drug-drug interactions. I cannot disagree with
this latter tenet. He is likely correct when he states that nothing would have happened
had he not filed a complaint with the College. As he sought advice as to whom this
tragedy should be reported, he was advised there is no reporting requirement. The extent

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Page 11
of the recommendations in the Coroner's Report to this College and to the College of
Physicians and Surgeons was simply: "The circumstances of this death be reviewed for
information and appropriate follow-up."
[58] The investigation was adequate in that there was little else to discover. Two
pharmacists ignored drug-drug interaction warnings leading to death and admitted they
had done so.
[59] The reasonableness of the disposition is a more difficult question. The disposition,
which was agreed to, resulted in the remedial consequence the College Inquiry
Committee thought appropriate, including in the case of Registrants 2 and 3, suspension
of their licences for 30 days, public notification of their suspension, a requirement to take
specified additional training and to submit to a practice audit.
[60] One of the questions the Review Board must always consider in a case where a
“request” under s. 36(1) was “accepted”, especially in a serious case, is whether the
agreed outcome reasonably serves the public interest. That is always a risk in any
process that might involve negotiation and ends in an agreement and does not proceed
to formal discipline. In this case, however, I am satisfied that the process was legitimate
and that the outcome was within the range of reasonable outcomes, and that the Inquiry
Committee did not sacrifice the public interest with these consequences, which could just
as easily have been the result of a formal discipline hearing. In my view, the disposition
was reasonable.
[61] Separate from the particular consequence to the Registrants, the Complainant
would have been satisfied to some extent had the College taken steps to establish, on a
more systemic level, necessary reporting requirements when drug-drug interactions
occur and especially when serious injury or death occurs so that others do not suffer as
has this family. To that I say: do not despair. That could still be an outcome of this
complaint as the College considers the "appropriate follow-up" suggested by the Coroner.
[62] The Institute for Safe Medication Practices Canada (ISMP) encourages healthcare
workers to report deaths to the coroner if a medication error is suspected to have caused
or contributed to a death, enhancing patient safety by sharing learning. The Canadian
Medication Incident Reporting and Prevention System (CMIRPS) is a collaborative
program of Health Canada, the Canadian Institute for Health Information (CIHI), the
Institute for Safe Medication Practices Canada (ISMP Canada) and the Canadian Patient
Safety Institute (CPSI). Its goal is to reduce and prevent harmful medication incidents in
Canada.
[63] There are at least three organizations that accept reports of incidents that lead to
severe outcomes, including death, as a result of medication errors. While I have no
authority to require it, I find the unique circumstances of this case warrant my respectfully
offering some observations arising from the tragic circumstances of this case. One is that
all health practitioners in British Columbia be required, as they are in the case of gunshot
wounds, to report medication incidents with adverse outcomes in order to reduce the

 DECISION NO. 2014-HPA-106(a); 2014-HPA-107(a); 2014-HPA-108(a)
Page 12
number of occurrences in future care. It should not be left to grieving families to report
these incidents.
[64] To bring a legislated requirement of this type into being, encompassing all health
colleges operating under the Act, would likely be an optimal solution. Even where some
errors might fall “between the cracks” in the functional gap between professions (as in
this case, between medicine and pharmacy), a sector-wide reporting requirement would
go a long distance toward ensuring that the maximum future learning and prevention
benefits - perhaps including the updating of drug interaction databases - are extracted
from unfortunate incidents.
[65] Closer to home, I respectfully offer the same reporting suggestion to the College in
this case, given the wide range of powers it possesses to regulate its registrants under its
bylaw-making authority (e.g., ss. 19(1)(k), (k.1) and (x) of the Act).
[66] I also encourage the College to review its continuing education requirements for
College registrants, including the reporting, recording and monitoring of annual
continuing education activities, and strengthen them if necessary.
[67] I will reiterate that the Review Board has no formal authority to issue systemic
directions in the course of a decision made in an application for review of an Inquiry
Committee disposition. The suggestions set out in the above paragraphs are offered in
the unusual circumstances of this case, and as a courtesy to the College and to the
Province in the spirit of public protection that is the core duty of a College as set out in s.
16(1) of the Act.
VII

DECISION

[68] I find the Inquiry Committee’s investigation adequate and the disposition
reasonable as it falls within a range of acceptable and rational possibilities. Accordingly,
the disposition is confirmed.
[69] In making this decision, I have considered all of the information and submissions
in the record whether or not specifically reiterated herein.

“Marilyn Clark”
Marilyn Clark, Panel Chair
Health Professions Review Board
November 26, 2015