College registrants have a legal and ethical obligation to promote and protect the best interests of their patients. The majority of College registrants are competent and skilled practitioners who work hard to uphold this obligation and maintain patient confidence by providing safe and effective pharmacy care.

However, there are times when a patient, co-worker, employer or other health care professional may have a concern about the pharmacy care delivered by a pharmacist or pharmacy technician. The College’s complaints resolution process is designed to deal with such circumstances and is grounded in the College’s mandate to protect the public.

2020/21 Complaints and Investigations Statistics

Contacting the College about a Complaint

If you have a concern about the care you received from a pharmacist or pharmacy technician, the best place to start is to speak directly with that person about your concern. Simple miscommunications are often at the root of many complaints, and although it may be difficult, a face-to-face discussion is often the best way to resolve an issue.

If you are unable to resolve the concern with the pharmacist or pharmacy technician, please contact the College’s complaints line at 1-877-330-0967.

Learn more about the complaints process at

Posting of Discipline Hearing Notifications

The College publishes citations and Discipline Hearing Notifications as individual items in the ‘News’ section of its website. These notifications will also appear on the College’s homepage. The College may include information about upcoming Discipline Hearing Notifications in its monthly ‘ReadLinks Roundup’ email, which is sent to all pharmacists and pharmacy technicians.

Previously, citations for Discipline Committee hearings were published under ‘Discipline Hearing Notifications’ on the College’s website 2-4 weeks prior to a scheduled hearing.

When the College’s Discipline Committee takes action under Section 39 (2) of the Health Professions Act, these actions are published as ‘Complaints Outcomes’ on the College’s website.

As a Health Professions College under the Health Professions Act ("HPA"), the College’s mandate is to serve and protect the public. Greater transparency assures the public that they can trust their pharmacies, pharmacists, and pharmacy technicians to provide safe and effective pharmacy care.

Learn more about our complaints and discipline publication policy.

Summary of Relevant Statistics

The College’s Inquiry Committee investigates complaints and concerns regarding a registrant’s conduct, competency and/or ability to practice and decide on an appropriate course of action pursuant to legislation. All complaints are received and resolved by:

  • informal resolution through remediation and correspondences,
  • formal complaints process with resolution through remedial activities, reprimands, suspensions and practice restrictions, or
  • referral to the registrar with direction to issue a citation and begin disciplinary proceedings.

In 2020/21, the Inquiry Committee received and opened 150 complaints which involved over 270 registrants. Panels of the Inquiry Committee convened on 66 occasions to review and dispose of 137 cases and to reconsider 100 cases. Majority of these cases were resolved by way of consent with the registrant and resolved by remedial action. There were 8 registrants whose cases were reviewed and disposed of by the committee but have yet to sign their consent agreements at the time of reporting. There were two cases where the Inquiry Committee directed the Registrar to issue citations whereby the registrants failed to respond to the College. One registrant agreed to cancel his registration with the College.

The Inquiry Committee took no further action for 41 registrants as the conduct or competence of the registrant was found to be satisfactory or the complaint was unsubstantiated. The Inquiry Committee also took actions it considered appropriate to resolve the matter between the complainant and the registrant in 52 cases, whereby the registrant’s conduct and competence was found to be unsatisfactory but relatively minor. These actions may include reminders and recommendations for better practice and written letters of apologies to the complainants.

Six registrants’ citations and discipline hearings were cancelled as the matters were resolved by consent pursuant to section 37.1 or section 36 of the HPA. Section 37.1(1) of the HPA states that the registrant may give the Inquiry Committee a written proposal at any time before the commencement of a discipline hearing. In these instances, the orders are considered to be orders made by the Discipline Committee.

Section 35 Extraordinary Action

If the Inquiry Committee considers an action necessary to protect the public during the investigation of a registrant or pending a hearing of the discipline committee, it may, by order,

  • impose limits or conditions on the practice of the designated health profession by the registrant, or
  • suspend the registration of the registrant.

This action is only used in rare situations where it is necessary to protect the public in cases where there is an urgent public protection issue. In 2020/21, the Inquiry Committee made orders to impose limits and conditions on a registrant’s pharmacy practice pursuant to section 35(1)(a) of the  HPA, pending investigation into the registrants’ practice or discipline hearing. These included but are not limited to:

  • not be involved in any way in the preparation, compounding, manipulation and/or dispensing of injectable and/or sterile products to patients/clients or health care providers/prescribers for office use;
  • not act as a pharmacy manager or owner, to not act as a preceptor to students or be responsible for the supervision of other staff and/or registrants; and
  • must work under the direct supervision of another registrant acceptable to College staff.

Health Professions Review Board

Under section 50.53 the HPA, the Health Professions Review Board (“HPRB”) can:

  • on application by a complaint under section 50.6, review the adequacy of the investigation conducted by the Inquiry Committee and the reasonableness of its disposition;
  • on application by a registrant or complainant under section 50.57, review the timeliness of an investigation.

In 2020/21, there was one HPRB review requested by a complainant and the HPRB confirmed the disposition of the Inquiry Committee.

Summary of Inquiry Committee Dispositions

Medication Dispensing Errors

The most common complaints received at the College continue to be complaints related to medication dispensing errors, such as:

  • patients receiving the incorrect medication or strength of medication;
  • medications being dispensed and/or delivered to the wrong patient;
  • prescription labels containing incorrect information, or information inconsistent with the original prescription;
  • patients receiving expired medication; and
  • blister packaging errors, such as incorrect quantities and incorrect medication inside individual blisters.

In all the above instances, the root cause of the errors was an inadequate final check and/or inadequate patient counselling.

For most complaints involving a medication dispensing error, the Inquiry Committee took a remedial approach in its dispositions. Registrants who had been responsible for the final check and/or patient counselling for a prescription, but who had not followed legislative requirements for these steps, were requested to sign consent agreements containing terms and conditions in order to prevent an error from occurring again.  Examples of such terms include:

  • reviewing legislative requirements for final check and/patient counselling, and then signing a declaration to indicate understanding and future compliance;
  • undertaking (ie. make a written, professional commitment) to take certain steps to change or enhance their practice to prevent a recurrence of the error;
  • reading an article and/or taking a course related to preventing medication errors; and
  • writing a written reflection regarding their learnings from the article/course.

Professional Misconduct

The Inquiry Committee reviewed and disposed of cases related to professional misconduct that did not involve pharmacy practice. These cases included conduct such as, not responding to the College in a timely manner, or in some cases not at all, altering legal documents and registrants misrepresenting themselves. To resolve these matters, the registrants consented to terms imposed by the Inquiry Committee that included:

  • reviewing the College’s code of ethics tutorial;
  • paying a fine;
  • consenting to letters of reprimand in the range of one year to permanent; and
  • not being a preceptor or supervisor of pharmacy students for a period of time.

Inaccurate PharmaNet Recordkeeping

The Inquiry Committee disposed of cases related to inaccurate processing of daily-dispensed prescriptions and/or weekly or monthly processing. The Inquiry Committee determined that pharmacy staff dispensed prescriptions to patients for a quantity of seven days but processed those prescriptions once daily onto PharmaNet. This practice resulted in inadequate prescription preparation, inaccurate clinical assessments, incomplete PharmaNet checks, and false final checks. This practice ultimately resulted in inaccurate PharmaNet records for the involved patients.

The Inquiry Committee requested that the involved registrants consented to terms imposed by the Inquiry Committee that included:

  • fines ranging from $1000 - $7500
  • limits and conditions on being a pharmacy manager
  • complete the Jurisprudence Exam
  • complete an Ethics Course
  • letters of reprimand

Opioid Agonist Treatment

The Inquiry Committee reviewed a number of cases where other practitioners had submitted complaints about the way pharmacist registrants had dispensed OAT therapy to their patients. The practitioners were concerned that the registrants dispensed treatment contrary to their direction. For example, registrants were identified as having provided carries or split doses to patients where they were not authorized by the practitioner. The pharmacists involved in the incidents cited many factors for their decision making, including inadequate transitions in care, the inability to communicate with prescribers, and COVID related measures put into place by the Public Health Officer.

In most cases, the Inquiry Committee determined that the College registrants dispensed treatment contrary to the practitioners’ orders in response to scenario specific challenges and did so to ensure continuity of care. The Inquiry Committee reminded the registrants that their actions were considered exceptions to the rule, and that the registrants were required to follow PPP-66 and their associated policy guides when dispensing OAT.  Further, in each case the Inquiry Committee identified potential knowledge gaps in the registrants’ practice and directed registrants to complete remedial coursework to address these gaps.

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