Pharmacist fined, censured and struck off for error and attempts to cover it up

A senior pharmacist who blamed a colleague for a dispensing error he made himself has been struck off, censured and fined. Photo / 123RF

A senior pharmacist has been struck off after he blamed a colleague for a dispensing error he made himself.

The Health Practitioners Disciplinary Tribunal found Feras Dawood guilty of professional misconduct and cancelled his registration over the incident.

Dawood was the managing director and majority pharmacist shareholder of the Unichem Waiuku Medical Pharmacy when he made the error in May 2019.

In a decision by the tribunal dated May last year but only released today, it cancelled Dawood’s registration, censured him and fined him $5000.

He was also ordered to pay costs of $10,500 and no order was made for name suppression.

The charge concerned his role as the checking pharmacist in a dispensing error and his attempts to cover up his error and attribute blame to another staff member.

Dawood qualified as a pharmacist in 2002 and began practising in September 2004.

In 2019 he had a condition on his practice that he worked in association with another pharmacist at all times when dispensing medicines and that he was to be under the supervision of a Council-approved pharmacist.

A woman required hospital treatment after being prescribed the wrong medicine in an error the pharmacist tried to cover up. Photo / 123RF

A pharmacist known as “Ms A” was employed by the business and appointed as Dawood’s supervising pharmacist.

In March 2019 a new customer arrived with a prescription for 13 medications. Two months later a technician at the pharmacy incorrectly dispensed a repeat prescription by providing a blood-clotting medication instead of an antibiotic.

Dawood checked the medication prepared for the customer but failed to detect the dispensing error.

He signed the “checked by” section of the prescription’s Certified Repeat Copy [CRC] with his initials, “FD”.

A couple of days later the client collected the medication and then became increasingly unwell to the degree she activated her medical alarm, and was taken to hospital by ambulance.

The admitting doctor diagnosed an upper gastrointestinal haemorrhage, an acute kidney injury and hypovolaemia, which is an abnormal decrease in the volume of circulating blood plasma.

She was admitted to hospital for treatment.

The hospital pharmacist phoned the dispensing pharmacy and spoke first with the supervising pharmacist and then to Dawood, who was told of the woman’s condition as a result of having taken the incorrectly dispensed anticoagulant.

Dawood then looked for the CRC form generated for the dispensed medications and subsequently told the other pharmacy staff he could not find it.

Early in the morning of May 28, 2019, Dawood entered the pharmacy through the back door.

He then disposed of the original CRC for the antibiotic Rifaximin that had been created by the dispensing technician.

He created and printed two new CRCs, both of which he dated May 3, 2019; one was for the repeat dispensing of another medication Clonazepam, in which he signed using the technician’s initials in the “packed by” section and his own initials in the “checked by” section.

The other CRC was for the repeat dispensing of Rifaximin. On that one, Dawood signed the technician’s initials in the “packed by” section and the supervising pharmacist’s initials in the “checked by” section.

Dawood then placed the two newly created CRCs among a batch of other CRCs that had already been processed, then left the pharmacy through the back door.

Soon after he turned up at the pharmacy at the usual time and in the usual way, and proceeded to “find” the missing CRC for Rifaximin, that he had created earlier that morning.

Dawood told the supervising pharmacist that he had found it and showed her the false CRC on which he had recorded that she was the pharmacist who had checked the incorrectly dispensed medication.

She told him that the CRC did not reflect her usual checking process, as it did not have any of the usual markings she made on CRCs when she checked prescriptions.

Later that day the technician found the fake CRC for the repeat Clonazepam which showed her initials in the “packed by” field and Dawood’s initials in the “checked by” field.

Dawood emailed the client’s GP to say that she had been incorrectly dispensed anticoagulant Rivaroxaban instead of antibiotic Rifaximin.

He also advised Green Cross Health.

Despite the supervising pharmacist’s reaction she had not done anything wrong, Dawood insisted she was responsible for the error.

She was ultimately given extended stress leave.

Dawood completed an incident notification form and sent it to the Pharmacy Defence Association. He specified that the pharmacist involved was “Ms A” and the technician was “Ms C”, and wrote that the medication had been dispensed by Ms C and checked by Ms A.

It was ultimately found that Dawood was the pharmacist who checked the dispensing of Rivaroxaban 20mg which had been dispensed incorrectly instead of Rifaximin 550mg.

The second particular of the charge concerned Dawood’s actions following the discovery of the error.

The tribunal also found his actions amounted to dishonest conduct.