ETHICAL STATIONS

1. Case: Pharmacy Technician Mr. Ryan Henderson took Verbal Rx

for HCZ (25 mg bid as before)
Hi Ryan how r u today.
How is work going on, everything is ok.
You are working very hard I appreciate your determination and commitment.
You are the responsible technician of our pharmacy.
Ryan I have a concern regarding one thing with you.
You have received a verbal Rx from Doctors office?
Did you take patient name, doctor name and also did you take Dr phone #?
I really appreciate your help but u know what Pharmacy technician is not allowed to do that by
law for the benefit of patient. There are certain technical duties of technician which they have to
perform under direct supervision of pharmacist excluding verbal Rx.
Its not that I do not trust u but actually its my job and by law I have to do it by myself. It is
pharmacist job and responsibility as per drug act.
I should call Dr again to verify Rx.
She said it was different in the other pharmacy
It does not mean they are doing right thing. May be they are doing other way I cant comment on
their functioning. Law is same for all pharmacies.
She said that she was trying to help me as I was so busy
Thank you very much ,Well I understand that u r new here and you r not familiar with general
guidelines of the pharmacist and pharmacy technician roles so next time when its dr. office
calling for repeats or for new verbal Rx, dont take it by yourself but ask pharmacist on duty even
he is busy.
I have to call to doctor to confirm so I am taking the time anyway and in the mean time that time
u have taken for this rx. it is waste of time and double the work
You do not have to be upset, everybody has his own responsibilities and his own work that he
suppose to do and finally we are only one team working for best of patient.
I hope everything is clear now and I will not expect such incidence from you in the future.
Do you have any concern about that
I will give you the printout which will give you thorough review of pharmacy technician duties.
Further I will suggest you that you can join a continuing education program to update your
knowledge.
Ok that fine, let us continue our work right now, we have too much things to do.

2. Case: a note left by the night shift pharmacist to talk to the technician. He overheard her giving
OTC recommendations and talking about a patients prescriptions. The Tech. comes in and you
chat with her about thisShe used to do this at her previous pharmacy and it was ok. Explain
why it isnt legal issue etc. (college extract about duties are in front of you)
Solution
A pharmacy technician is a person employed to perform procedures of a technical nature
involved with dispensing a Rx. A Pharmacist may delegate activities related to dispensing
functions to a pharmacy technician under his supervision.
3. CASE:Your technician informs you that you are out of stock of Tylenol 1s.
He tells you that he already sold 5 bottles this morning (without his
consent).
Explain legalities to the technician that this is a controlled act performed by an RPh:
Tylenol 1 is a schedule 2 drug which require professional intervention from the RPh at the point
of sale and possible referral to MD .While prescription is not required, the schedule 2
medication is only available from the pharmacist and must be retained in area of pharmacy
where there is no public access .
Tech will argue that the former manager of the pharmacy allowed her to dispense Tylenol 1s.
Candidate must put onus to himself: I am sorry if he did not give you a thorough overview of
your duties. I will review them to you
RPh must be professional in handling the situation .RPh must explain to the tech that he has to
counsel the patient on using the Tylenol 1
4. Case: Confidentiality: Mother looking for information regarding her 16 year old
daughters medications (name and use).She was on antidepressant. Daughter wont talk
to her. She is worried about her.

Privacy Legislation

Model Guidelines for Pharmacists to Comply with Provincial Privacy Legislation

Pharmacists have an ethical obligation to protect the patient's right of

confidentiality and provincial pharmacy regulatory authorities have
developed policies or legislative instruments to guide the pharmacist in
meeting this obligation. Because of public concerns that individuals' privacy
may be violated when technologies such as computer networks, are used to
collect, store, use or transmit personal information, provincial governments
are implementing privacy legislation to protect personal information. During
the course of practice, pharmacists acquire medication and other medical
and personal information about their patients. When legislation is directed
towards individual health information, pharmacists then have both ethical
and legal obligations to respect the confidential nature of their patients'
personal health information and protect the privacy of the individual.
The twelve "Guiding Principles" listed below were developed by the
Pharmacy Registrars to form the basis of Pharmacists' Operational
Guidelines. The Guidelines were endorsed by NAPRA on April 21, 2001 to
provide member regulatory bodies with assistance in helping pharmacists
meet these legal and ethical obligations.
Guiding Principles to Protect the Patient's Right to Confidentiality
1. Health related information about an individual (personal health
information) belongs to the patient, but the electronic and paper records
that carry this information are the property of the pharmacy. Such records
include but are not limited to, prescriptions, patient profiles and reports,
which contain information that identifies an individual with a pharmacy
service.
2. The pharmacist has a duty to inform the patient of the anticipated use
(other than internal) or disclosure of personal health information collected.
3. The pharmacist can only use or disclose personal health information
with the consent of the patient. Consent can either be explicit, or inferred if
the pharmacist has fulfilled the duty to inform and has sufficient reason to
believe that the patient would consent under the circumstances. Exceptions
include preventing harm to the patient or if it is in the patient's best
interests (where lawful authority exists) or for any other purpose such as
research or education when the identity of the patient is concealed.
4. The pharmacist may collect and use personal health information only
for the purposes of providing pharmacy services.
5. The pharmacist may disclose personal health information only to
those who have a legitimate need for that information.
6. The patient can revoke consent at any time, but such revocation is
not retroactive.
7. Consent or revocation can be given verbally or in writing. When
consent is given verbally, the pharmacist must document the direction
especially when it relates to sensitive or potentially controversial
information.
8. Upon request of the patient, the pharmacist is obliged to allow the
patient to inspect records carrying personal health information and provide a
copy. Where the patient requests an amendment, the pharmacist shall
document the amendment in the person's record.
9. Where others such as pharmacy employees or information managers
have access to personal health information collected and stored by the
pharmacist, the pharmacist shall ensure that policies or formal agreements
(where needed), exist to protect the information.
10. The pharmacist shall establish policies governing the retention, security
and destruction of personal health information to maintain patient
confidentiality and privacy.
11. Before using or disclosing personal health information, the pharmacist
must take reasonable steps to ensure that the information is accurate,
complete and not misleading.
12. Lawful agents (such as guardians or executors of estates) can exercise
the rights of individuals.
Operational Guidelines for Pharmacists - Disclosure
Due to ethical and legal obligations, it is recognized that confidential
personal health information must or in fact should, be disclosed in certain
circumstances. Circumstances when confidential information may be
disclosed to third parties include:
1. The patient consents to release of the information. Written consent from
the patient should be obtained. At a minimum, the pharmacist should be
satisfied that the patient has expressly permitted the release of the
information sought. Otherwise, inferred consent as described in the guiding
principles is sufficient.
2. Release of the information is necessary to comply with the law. For
example:

a police officer presents a warrant

a pharmacist is served with a subpoena which requires delivery
of documents containing the patient records
release of the information is required by Rules of Court that
relate to production of information in a lawsuit
an inspector or investigator authorized under provincial
pharmacy legislation to have access to the records makes a request
to access the records
an inspector authorized under The Controlled Drugs and
Substances Act and/or The Food and Drugs Act to have access to the
records makes a request to access the records pertaining to
controlled drugs and substances or narcotic and controlled drugs

3. Police, other law enforcement agencies or officials, or provincial

professional regulatory authorities request the information and the
pharmacist deems it to be in the best interest of the public to provide such
information.
4. Pharmacists and other health care professionals request the information
for bona fide medical and/or pharmaceutical reasons where, in the
judgement of the pharmacist it is prudent to provide this information in the
interests of the patient:

to protect the mental or physical health or safety of the patient,

or
for pharmacy information sharing networks (i.e. telephone fan-
outs) to prevent the illegal or non-medical use of drugs

5. Release of the information to legal counsel is required for use in providing

legal services to the provincial pharmacy regulatory authority and/or one or
more of its members.
6. Pharmacists may disclose to a third party such as a commercial data
compiler, prescription information including the identity of the prescriber,
pharmacist and pharmacy, which does not and may not reasonably be
expected to, identify the patient. This information is provided on the
understanding that the third party will not disclose this information with
respect to the prescriber, pharmacist and pharmacy except in an aggregate
format (i.e., which does not disclose specific individual prescribing or
dispensing information), without signed consent from the prescriber,
pharmacist and pharmacy. The onus to obtain this consent is on the third
party requesting such information.

5. Case:Angry father comes to the pharmacy and asks for the use of the medication in the
vial. On reading the bottle, it is for his daughter, Melissa; medication is Diane-35 or
Tri-cyclen. The pack was obtained from his daughters room
Confirm patient
ask name and ask age
why you need to know
why patient did not come herself
Check profile and confirm patient and read medication silently
hide patient profile from anybody physically
We do not know exactly, some medications has multiple uses.
Doctor knows better the medical condition. For which he written or your daughter can
tell better.
Do you have written consent from patient?
Feel sorry that I cannot help.
Could not divulge any patient information without patient consent that it is legal (hands
are tied and bound by the law).
Confidentiality: explain to her that as a health professional I must follow the ethics of
confidentiality.
Give example that if some one gives my personal information to anybody without any
consent that I will not feel good..I may sue that Person.
On dialogue: Agent will threaten RPh that he could obtain information about the
medication from other pharmacies. Law is for every pharmacy. It does mean that they
are doing right. May be mistaken
She would be persistant but stick to your ethics.
If agent insists; RPh may tell patient that the medication has several uses (hormone
replacement, acne, androgen dependent seborrhea, alopecia or hirsutism).
progestonic, estrogenic ,anti androgen properties
Agent will tell that he knows it is an oral contraceptive; is she using other
medications of the same kind? Tell patient that the medication dose is too low to
be used as a pill;
RPh could not give any information on her medical profile.
it is best to talk heart to heart with your daughter or get advise from family doctor
on how to proceed
 ask that some time come with your daughter and as healthcare professional I can
work as an intermediate between you and your daughter and sort out any doubt.

6. Case:Agent comes to the pharmacy and requests for a copy of his familys reciepts for
tax purposes.
Confirm patient
ask name and ask age
why you need to know
why patient did not come herself
Check profile and confirm patient and read medication silently
hide patient profile from anybody physically
RPh should ask for a letter/certificate of authorization that the family member allows the
dad/father to get the receipts.
Feel sorry that I cannot help.
Could not divulge any patient information without patient consent that it is legal (hands are
tied and bound by the law).
Confidentiality: explain to her that as a health professional I must follow the ethics of
confidentiality.
Actor will insist that the other pharmacist allowed him to get the receipts before .Explain to the
patient that the RPh may had made a mistake and explain that the law does not allow this
(violation of code of ethics) .
If patient still insists: the RPh will place the receipts in a sealed envelope and a written notation
on the envelope: to be opened by NAME OF PATIENT and the seal is signed by the
pharmacist. This should be explained to the patient.

7. Case: Inspector for profile

Identify patient and inspector.
Why need and why pt. did not come himself.
have written consent.
offer him alternatives .Court orders or patient himselp.
Want to help but cannot.
Appreciate your efforts.
Confidentiality
A ssure that I would more than happy to serve under legall situation.

8. Case: How to teach a new technician to destroy the expired narcotic drugs.
Letter contains products details, why expired or unfit for use
To burea of drug survieliance health canada ottwa
All narcotic except targeted substances
Bimonthly
Fill form
Send us agreement
Witness pharmacist, intern, college member
2 pharmacist sign a report and send to college
Consider environmental regulations
 Tablet crush/capsules disolve. Liquid mix, ampoulebreak/mix .wash room
Flush several time

9. Case:Talk to intern about discarding of expired benzo targeted substance. (She

asked can we flush in the drain.) Health Canada manual Discard and register it
and sign the witness pharmacist or other colleagues.

Yes. The only change to the procedure is that requests for destruction of narcotics and
controlled drugs should now be sent to the Office of Controlled Substances in Ottawa, rather
than the regional office. Your list of unusable narcotic and/or controlled drugs should now be
mailed or faxed to the Drug Control Unit at:

Compliance, Monitoring and Liaison Division

Office of Controlled Substances
Drug Strategy and Controlled Substances Programme
Health Canada
Address Locator: 3502B
Ottawa, Ontario K1A 1B9
Tel: (613) 954-1541 Fax: (613) 957-0110

You will then receive a letter acknowledging receipt of your request from the Office of
Controlled Substances. You may destroy the products once this confirmation has been
received. The destruction must be witnessed by another health professional such as a
pharmacist, pharmacy intern or a Field Representative from the Ontario College of
Pharmacists. (The College recommends that drugs be treated similar to hazardous materials
and be destroyed through a waste disposal service.)

The inventory of destroyed material is to be signed and dated by both parties. It should
then be placed in the narcotic prescription file on the date destroyed and/or stapled to the
Pharmacy Narcotic and Controlled Drug Register for Receipts (green pages).

This procedure is outlined in the letter of acknowledgment that is sent to the pharmacy by
the Head of the Drug Control Unit.

Please note that a request to destroy unusable benzodiazepines and other targeted
substances, as listed in the Benzodiazepines and Other Targeted Substances Regulation, is
not required but the quantities must be recorded and the destruction witnessed as done
with narcotics and controlled drugs.

So only for Narcotics(with N besides their monographs) and controlled substances part I,
part II and Part III(with C besides their monographs) require a request to be send to the
office of controlled substances and we have to wait for their approval before destroying and
documenting the destruction in presence of the other health-care professionals(u know
which).

For Benzodiazepines and Targeted substances(with C/T besides their monographs) we only
need to destroy in front of other health-care professionals and document the destruction. No
need to send any kind of request.
Case 10: Dentist faxed the prescription of Mevacor (Lovastatin) for 1 month for his father
During interview you find out because his fathers doctor is on vacation
Father is travelling for 2 weeks. He has 2 days supply
Profile HCTZ 25 mg for BP
Tell politely to that it was out of his scope of practice plus it is unethical to write for your
own father
Your father is having it for 6 months, Dr needs to check LDL, HDL, total cholesterol
@3,6 and 12 months for LFT TC 397
Ask about the muscle pain
Offer to book an appointment for his father
(May be you can give 7-14 days of Mevacor on your professional judgment)-I think you
cant give even a single tablet on this prescription. It as good as a pharmacist prescribing
mevacor for his patient.
Dentists may prescribe medications that are within their scope of practice. There is no
formal list of these medications.
Dentistsreceivetheirauthoritytoprescribeordispensedrugsby
virtueofvariousprovincialandfederalstatutes,includingthe
DentistryAct,1991,theDrugandPharmacies
RegulationAct,theFoodandDrugsAct,andthe
ControlledDrugsandSubstancesAct.The
DentistryAct,1991(RHPA)liststheeightcontrolled
actsfordentistry,oneofwhichistheprescribingordispensingof
drugs.
However,suchprescribingordispensingofdrugsislimitedtothe
treatmentorpreventionofconditionsrelatedtothescopeofpractice
ofdentistryandforthedentistspatientsofrecord.
Becausedentistsprescribingprivilegesarelimitedtothediagnosis,
treatmentorpreventionofconditionswithinthescopeofpracticeof
dentistryforpatientsthatthedentististreatingfortheseconditions
anddentistsdonottreatthemselves,theycannotselfmedicateor
prescribedrugsforthemselves.Theyalsocannotprescribedrugsfor
theirfriendsorfamilyfornondentalpurposes.
Dentistscan,however,prescribedrugsfortheirfamilymembersas
longastheyareprescribingthemedicationforthediagnosis,
treatmentorpreventionofconditionsoftheoralfacialcomplexand
withinthescopeofpracticeofdentistry,andaretreatingthefriends
andfamilymembersfortheseconditions.Theycannotprescribe
drugsfornonpatientsorforconditionsthattheyarenottreating.
Thescopeofaspecificdentistspracticeandtheconditionforwhicha
dentististreatingaspecificpatientwilldeterminewhichdrugsit
wouldbereasonabletoprescribe.
Recently the Royal College of Dental Surgeons ruled that nicotine replacement products are
within the scope of practice. The new product containing buproprion had also been included
in the scope. Before becoming involved with smoking cessation programs for their patients,
dentists should take a course(s) that follows the RCDSO criteria. If you have a questions
relating to the practice and prescribing by dentists, you may contact the RCDSO, tel:(416)
961-6555.