Objective: This study aims to determine the reasons for disciplinary action and resultant consequences for Canadian pharmacists and any associations with demographic factors.

Methods: Regulatory body disciplinary action cases from 10 Canadian provinces were coded. Demographic information was coded.

Results: There were 665 pharmacist cases from nine provinces between January 2010 and December 2020. The rate of disciplinary action was low (1.37 cases/1,000 practitioners/year). Professional misconduct was the most common category of violation. Male pharmacists were overrepresented in disciplinary action cases. Most cases involved community pharmacists.

Conclusion: This study is the first, to our knowledge, in Canada to analyze the demographic factors of pharmacists subjected to disciplinary action. It updates a previous review of pharmacist disciplinary action (Foong et al. 2018).

Introduction

Regulatory body complaints and disciplinary action processes exist to protect the public. In Canada, most complaints are resolved at a lower level committee, and serious cases of professional misconduct or clinical incompetence are heard by a higher level disciplinary committee. Such processes provide the public with a channel to voice their concerns and are crucial to protect the public from practitioners providing unsafe care or those who are conducting themselves unethically.

In an effort to increase accountability and transparency to better protect the public, recent changes have been recommended to improve regulation in some provinces. For example, British Columbia plans to make significant changes to health professional regulation, including a reduction in the number of regulators, the creation of an oversight body and the creation of a new disciplinary process that is separate from the regulatory body (Steering Committee on Modernization of Health Professional Regulation 2020). In addition, Quebec, Ontario and Alberta have enacted legislations in recent years implementing mandatory penalties for health professionals found guilty of sexual abuse, and the physician regulator in Saskatchewan has adopted a similar approach (An Act to Protect Patients 2018; College of Physicians and Surgeons of Saskatchewan 2020; Inquiries Division 2018; Owens 2018; Protecting Patients Act 2017). However, the impact of different legislations and regulatory policies across Canada is not known, and the impact of these specific policy changes on disciplinary outcomes remains to be seen.

Previous work reviewed disciplinary action cases for Canadian pharmacists from 2010 to 2017 and found that most violations involved unprofessional conduct or dishonest business practices, and that disciplinary action for an isolated, clinical incident was uncommon (Foong et al. 2018). Reviews of Canadian physician disciplinary action cases have also been conducted, which found that sexual misconduct was the most frequent violation, followed by standard of care issues and unprofessional conduct (Alam et al. 2011). The objective of this study was to characterize disciplinary action cases for pharmacists by identifying the reasons for being disciplined, penalties applied and any associations with demographic factors. This study updates our previous review of pharmacist disciplinary action, seeks to identify changes in disciplinary outcomes in recent years and analyzes demographic factors, which the previous study did not conduct (Foong et al. 2018).

Methods

Inclusion and exclusion criteria

Regulatory body disciplinary action cases for pharmacists from 10 Canadian provinces published between January 2010 and December 2020 were included. Cases from the three Canadian territories were excluded because pharmacists are typically regulated by a branch of the government rather than an independent regulatory body (National Association of Pharmacy Regulatory Authorities n.d.). Disciplinary cases from most provinces were publicly available and accessed from regulatory body websites or online from the Canadian Legal Information Institute. Ethics approval was not required for publicly available cases. For cases that were not publicly available, ethics approval was obtained from the University of Waterloo Research Ethics Board (REB #43844) and/or the researchers entered into a research agreement with the regulator.

Only cases that described both a violation and a penalty were included; disciplinary cases that involved an appeal, a request for reinstatement or a request to remove conditions on a licence were excluded. Cases were also excluded if either the initial hearing or the penalty decision was before 2010 or after 2020, if the case involved pharmacy students or if the case involved a pharmacy and not a pharmacist. Cases that described a violation and a penalty for multiple pharmacists found guilty of the same violation were counted as separate cases under each health professional. For pharmacists who held active licences in more than one province and were disciplined for the same violation in these provinces, the case was counted only in the province that conducted the original investigation.

Of note, in our previous review of pharmacist disciplinary action, the sample included 74 cases from British Columbia, which included lower level complaints, as well as higher level disciplinary cases, while in this study, we included only the disciplinary cases, which totalled three cases (Foong et al. 2018).

Case coding

Violations, penalties and demographic factors of the pharmacists subjected to disciplinary action were coded for each case. Violations were coded into three categories that were adapted from our previous pharmacist review (Foong et al. 2018): (1) professional misconduct, (2) clinical incompetence and (3) dishonest business practices. Professional misconduct was defined as violating the standards of practice or legislation governing pharmacy practice but did not include clinical incompetence. Clinical incompetence included any violation involving clinical performance or treatment. Dishonest business practices included any violation with financial gain as a motive, such as inappropriate advertising or fraudulent billing. Codes within each category were adapted from codes from our previous research (Foong et al. 2018). Information on the following demographic factors were coded from the case or obtained online from the regulatory body's online register of professionals: age, gender, practice setting, practice specialty, number of years in practice, country of education and previous disciplinary action. Due to limited demographic information available, not all demographic factors were analyzed further.

The author AFR inductively coded a selection of cases, adding and revising codes. AFR and another researcher, Ariane Fung (AF), then independently coded 50 cases. Discrepancies were solved by discussion, and the coding framework was adjusted as necessary. The final coding framework was used by AFR and AF to independently code the data using Microsoft Excel. Due to unavailability of a research assistant, the first 51% of the cases were coded independently by both AFR and AF, and the remaining cases were coded by AFR alone. Cases from Quebec were read in English using Google Translate.

The rate of disciplinary action was calculated using pharmacist workforce data from the Canadian Institute for Health Information (CIHI 2011, 2021). Since pharmacist workforce data for Quebec in 2010 were not available, the overall rate was calculated from 2011 to 2020. Pearson's correlation coefficient was calculated in Microsoft Excel to determine any association between the rate of disciplinary action over time and the rate of disciplinary action and certain penalties. We hypothesized that provinces with lower rates of disciplinary action would reserve only the most serious cases for disciplinary action and would, therefore, be more likely to use severe penalties such as licence revocation and licence suspension. Similarly, we hypothesized that provinces with higher rates of disciplinary action hear less serious cases at the disciplinary level and would be more likely to use less severe penalties such as fines or professional development.

Results

A total of 665 pharmacist cases from nine provinces were included in this study. Cases from Prince Edward Island were not available, and a research agreement or freedom of information request was needed to access cases from British Columbia and New Brunswick. The distribution of cases and occurrence of each category of disciplinary action by province is illustrated in Figure 1.

FIGURE 1. Disciplinary action cases against pharmacists according to province

Reasons for disciplinary action

Overall, the most common category of disciplinary action was professional misconduct (54%), followed by clinical incompetence (39%) and dishonest business practices (37%) (as many cases involved multiple violations that often fell into more than one category of disciplinary action, the percentages exceed a sum of 100%). Quebec differed from the other provinces, in that clinical incompetence was the most common category. Quebec also had many more cases than the other provinces, comprising 48% of the sample. When the other nine provinces were analyzed separately from Quebec, professional misconduct remained as the most common category (72%), followed by dishonest business practices (36%) and clinical incompetence that was the least common (28%). The most common categories and reasons for disciplinary action are listed in Table 1, available online here.

Isolated incidents

Overall, 129 cases involved isolated, one-time incidents that resulted in disciplinary action. Of these, 109 were clinical incidents, 100 of which were from Quebec. Of the 109 cases, the most common reasons for disciplinary action were dispensing the wrong dose of a medication (40), dispensing the wrong drug (34) and inappropriate dispensing of non-controlled drugs (17). Fines and/or costs of the investigation were the most common penalties and were used in 98 cases. The next most common penalties were reprimands (17) and professional development (14).

Rate of disciplinary action

The rate of disciplinary action was low: 1.37 cases/1,000 practitioners/year. Disciplinary rate varied by province, with Quebec having the highest rate and British Columbia having the lowest rate – a 57-fold variation. Ontario and Alberta had the highest correlation between year and rate of disciplinary action, demonstrating a moderate correlation between rate of disciplinary action and time. Manitoba, New Brunswick, Nova Scotia and Newfoundland and Labrador showed no or very weak correlation. Rate of disciplinary action and correlation coefficients are outlined in Table 2.

Source of complaint

Information on the source that/who lodged the complaint with the regulatory body and triggered the investigation was not reported in 40% (265/665) of the cases. After “unknown,” the most common sources were the regulatory body (108 cases, 16%), healthcare providers (92 cases, 14%) and the patient or the patient's family/agent (72 cases, 11%). Other sources included the police, government sources (e.g., publicly funded insurance) and self-reporting. Cases in which the regulatory body identified the violation often involved cases of previous disciplinary action where the practitioner was being monitored or violations that were detected on pharmacy practice site visits.

Sexual misconduct cases

Sexual misconduct was not a common reason for disciplinary action. Sexual abuse was the reason for disciplinary action in 19 cases (2.9%), and sexual harassment was the reason in 10 cases (1.5%). Cases originated from British Columbia, Alberta, Ontario and Quebec. Pearson's correlation coefficient (r) for sexual misconduct cases was 0.50, indicating a moderate correlation between sexual misconduct cases over time. However, only Ontario had a moderate correlation (r = 0.57), with the other provinces having no/very weak correlation, suggesting that the Ontario cases were responsible for the trend in increased sexual misconduct cases.

We were unable to assess whether harsher penalties were administered as a result of the new legislation since most sexual misconduct cases involved violations that were committed before the legislation change. Only one case from Ontario fell under the updated legislation; this case ended in licence revocation.

Penalties

Across provinces, the types of penalties used were similar, but provinces varied in the frequency with which types of penalties were used (Table 3, available online at here). Most cases used multiple types of penalties. Penalties included fines and/or payment of costs of the investigation, apology, publication, reprimand, conditions placed on a licence to practice, professional development, attending counselling/ongoing fitness to practice assessments, suspension (temporary loss of a licence) and licence revocation (permanent loss of a licence).

Rate and licence revocation had a moderate negative correlation (r = –0.56), where provinces with lower rates were more likely to use licence revocation as a penalty. There was a strong, negative relationship (r = –0.78) between professional development and rate of disciplinary action, where provinces with lower rates of disciplinary action were more likely to use professional development as a penalty. We excluded British Columbia from the professional development and conditions on licence calculations, since British Columbia had three cases in total, all of which involved licence revocation, so it is understandable that other penalties would be less likely to be used. There was also a strong, negative relationship (r = –0.90) between rate of disciplinary action and conditions placed on a licence to practice, where provinces with lower rates of disciplinary action were more likely to place conditions on the pharmacist's licence to practice. No significant correlation was found between rate of disciplinary action and fines (r = 0.39), rate of disciplinary action and costs of the investigation (r = –0.36) or rate of disciplinary action and suspension (r = –0.36).

Characteristics of those disciplined

GENDER

Information on gender was available for 659 of the 665 cases. Male pharmacists were disciplined in 467 of the 659 cases (71%), while females were disciplined in 192 of the 659 (29%) cases. Male pharmacists are overrepresented in disciplinary action cases as they make up only 40% of the Canadian pharmacist workforce (CIHI 2021).

PRACTICE SETTING

Community pharmacists were involved in 652 of the 665 (98%) cases. Three cases involved hospital pharmacists, one case involved a pharmacist practising in both hospital and community and nine cases involved other/unknown practice settings.

YEARS IN PRACTICE

To estimate the number of years that a pharmacist has been practising, we used two metrics. First, we used “number of years licensed,” which captures the number of years that the professional has been licensed with that particular regulatory body but does not capture past registrations in other jurisdictions. Information on number of years licensed was available for 504 of 665 (76%) pharmacist cases, with a median of 18 years (range: 1–58).

The second metric used was “number of years since graduation,” which assumes that professionals practised continuously since graduation from their entry-to-practice pharmacy education. This information was available for 215 of 665 (32%) cases, with a median of 26 years.

PREVIOUS DISCIPLINARY ACTION

Previous disciplinary action for pharmacists was a factor in 66 (10%) cases. This does not include cases in which pharmacists had a previous finding at a lower level committee. Of these 66 cases, 59 received a suspension or licence revocation or resigned their licence. Licence revocations were overrepresented, compared with the overall sample, where 17 out of 41 (41%) cases involving previous disciplinary action resulted in revocation. An additional three cases involved resignation of the pharmacist's licence to practice, where the pharmacist agreed to not seek licensure again.

The most common violations among those with previous disciplinary action were breaching a condition on one's licence to practice (24/66, 36%), failing to follow college requirements for practice site (15/26, 23%), failing to co-operate with college investigation (13/66, 20%) and fraudulent billing (11/36, 17%).

Discussion

This review of pharmacist disciplinary action found that professional misconduct was the most common category for disciplinary action across nine Canadian provinces and that the rate of disciplinary action was low and consistent over the study period. This review is the first, to our knowledge, in Canada to describe the demographic factors associated with disciplinary action for pharmacists, and it updates a previous review of pharmacist disciplinary action (Foong et al. 2018).

Reviews of pharmacist disciplinary action have found that fraudulent billing practices (Foong et al. 2018) and medication-related offences (Walton et al. 2019) were the most common reasons for disciplinary action, while studies of physicians have shown that sexual misconduct was the most common reason (Alam et al. 2011). However, many differences between professions such as practice setting, scope of practice and regulatory practices/regulatory legislation could influence disciplinary outcomes.

Regarding demographics, our study agrees with other research in pharmacy and other health professions, which report that men are overrepresented in disciplinary action cases compared with the general workforce (Foong-Reichert et al. 2021; Spittal et al. 2016; Tullett et al. 2003; Unwin et al. 2015). Our research also agrees with the research by Tullett et al. (2003) concerning UK pharmacists, where most cases involved community pharmacists and multiple reasons for disciplinary action. While our finding that more years since graduation was associated with disciplinary action agrees with the research from other professions (Foong-Reichert et al. 2021), Walton et al. (2019) found that age was not associated with the increased risk of disciplinary action in pharmacists.

Rate of disciplinary action

Since a disciplinary action is typically reserved for only the most serious cases, it was not surprising that the rate of disciplinary action overall was low, which agrees with research from other professions. Our research adds to the literature by demonstrating that the rate of disciplinary action overall has remained steady. Some provinces did see an increase in disciplinary action cases, which have also been reported on regulators' annual reports (Alberta College of Pharmacy 2022; Ontario College of Pharmacists 2018, 2021). However, as not all provinces had an increase in disciplinary action, it is possible that more complaints are being lodged with regulators, but that these are being resolved before the case progresses to the higher level disciplinary committee. Reasons behind why more complaints are being lodged are unknown.

We noted a marked variation in disciplinary action rates across provinces that is not due to workforce changes. Variation in disciplinary action rates across jurisdictions has been previously described in dentistry and medicine (Damiano et al. 1993; Harris and Byhoff 2017; Munk 2016), with researchers speculating the possible reasons for these variations. These include different thresholds for deciding what types of cases should be resolved at a lower level committee versus what types of cases should be escalated to a higher level committee (Harris and Byhoff 2017). Different college agendas also influence the types of disciplinary cases that are heard, such as in our previous work (Foong et al. 2018) where Quebec disciplined many pharmacists for accepting kickbacks from pharmaceutical companies, or where many New Brunswick pharmacists were disciplined for practising outside their scope of practice by administering injections (Foong et al. 2018). Different compositions of members on the panels and committees that decide how a case should be processed might also influence outcomes, especially as more public members are being included in the decision-making process.

Rate of disciplinary action and penalties

We found that only professional development and conditions on licence had a strong correlation with the rate of disciplinary action, where provinces with lower rates of disciplinary action were more likely to use these penalties. The reasons behind this finding are unknown. Professional development involves not only clinical skill development but also attending ethics courses or business courses or retaking a jurisprudence exam. While Quebec had many clinical cases, only 1% of the cases used professional development as a penalty. In many cases, regulatory legislation dictates the possible penalties that can be used so it is possible that intra-provincial factors, such as legislation or case precedent, affect which penalties are used.

Other trends

It is too early to determine whether there has been an increase in sexual misconduct cases or harsher penalties after the passage of new legislation. This could be due to a few reasons. First, it can take months or years before a decision and penalty are determined, meaning that the impact of the legislation change is yet to be seen. Second, the legislation that is applied to a case is the legislation that was in place at the time of the offence, and most of the cases heard after the legislative change were for offences committed before the change. Third, sexual misconduct cases in pharmacists are low overall, especially when compared with other professions, such as medicine (Alam et al. 2011), so it is possible that the sample size is too small to draw conclusions.

Transparency

Although we were able to include nine out of 10 provinces in this study, transparency in disciplinary action against pharmacists in Canada continues to be a more significant problem than for other health professions. At the time of this study, disciplinary cases from the 10 provincial physician regulatory bodies in Canada were publicly available online. Regarding online registers of professionals, all provinces have an online database where a health professional may be searched. However, each province includes varying levels of information on these registers, ranging from the simplest that might include whether the professional's licence is active or suspended and their place of practice to others that might include educational institution attended, previous disciplinary action or extra services that the pharmacist can provide, such as injection administration. It remains to be seen whether the lack of transparency in access to disciplinary cases and in online registers of pharmacists is due to a lack of legislation encouraging transparent publishing practices or due to a lack of compliance with the existing legislation. If it is the former, then changes in provincial legislation governing health professionals could mandate increased transparency and more detailed online registers.

Limitations

A few limitations impacted this study. First, the drawing of associations between demographic factors and disciplinary action was limited due to inconsistent reporting of demographic information on online college registers or in case documents. Second, this study included regulatory body disciplinary action cases but was unable to capture the differences in complaints and disciplinary processes among colleges in Canada as most complaints' data are not publicly available. Since each college could have a different process for deciding how to move complaints through these two levels, it is possible that two colleges might process similar cases differently, resulting in more disciplinary cases in one province compared with another. As mentioned in the Methods section, this study included only higher level disciplinary cases from British Columbia, while our previous pharmacist review included cases from the lower level committee as well; this accounts for some differences in results compared with those from the previous review (Foong et al. 2018).

Conclusion

While this study identified that the rate of disciplinary action is low across Canada and confirmed the most common reasons for disciplinary action for Canadian pharmacists, the influence of legislation and regulation policy on the regulatory body complaints and disciplinary action processes is unknown. Areas for future research are numerous. More research on the types of penalties assigned in a disciplinary case, as well as whether these penalties are effective, is needed. Future research could investigate the factors driving the variation in disciplinary processes and outcomes and the influence of policy and legislation on disciplinary outcomes. In addition, access to data from lower level complaint committees would expand our knowledge of how the lower level processes and higher level disciplinary processes work together. Characterizing and understanding current disciplinary practices is necessary in order to evaluate and improve regulatory practices and protection of the public.

Funding

Ai-Leng Foong-Reichert was funded by the Ontario Graduate Scholarships and the Canadian Institutes for Health Research.

Correspondence may be directed to: Sherilyn K.D. Houle. Sherilyn can be reached by e-mail at sherilyn.houle@uwaterloo.ca.

Mesures disciplinaires imposées aux pharmaciens : pour quelles raisons les pharmaciens ont-ils des ennuis?

Résumé

Objectif : Cette étude vise à déterminer les raisons pour lesquelles sont prises des mesures disciplinaires envers les pharmaciens canadiens et les conséquences qui en résultent ainsi que toute association avec des facteurs démographiques.

Méthodes : Les cas de sanctions disciplinaires d'organismes de réglementation de 10 provinces canadiennes ont été codés. Les renseignements démographiques ont été codés.

Résultats : Il y a eu 665 cas de sanctions disciplinaires envers des pharmaciens dans neuf provinces entre janvier 2010 et décembre 2020. Le taux de mesures disciplinaires est faible (1,37 cas/1 000 pharmaciens/an). La faute professionnelle constitue la catégorie de violation la plus courante. Les hommes pharmaciens sont surreprésentés dans les cas de mesures disciplinaires. La plupart des cas concernent des pharmaciens communautaires.

Conclusion : Cette étude est la première au Canada, à notre connaissance, à analyser les facteurs démographiques des pharmaciens qui font l'objet de mesures disciplinaires. Elle met à jour un examen précédent des mesures disciplinaires prises à l'encontre des pharmaciens (Foong et al. 2018).

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