September 5, 2013
Pharmacist admonished in veterinary case
He needlessly alarmed pet owner about prescription, regulators found
By: Edie Lau
For The VIN News Service
A pharmacist who scared a customer about the amount of anti-anxiety medication prescribed to her dog following surgery has been issued a “notice of correction” by the Washington State Board of Pharmacy.
Photo by Kourtney Ott
Roo, a 97-pound Chesapeake Bay retriever, received an insufficient dose of medication after his owner was given misleading information by a pharmacist with no training in veterinary pharmacology.
Comments made by the pharmacist Amro Abu-Hallawah, supervisor of a Fred Meyer pharmacy in Tacoma, Wash., misled the customer into believing that if she gave the medication as prescribed by her veterinarian, the dose could kill her dog, a state Department of Health investigation found. The medication was diazepam, better known by the brand name Valium.
The notice of correction issued to Abu-Hallawah on June 27 is not a formal disciplinary action. According to the document sent to the pharmacist, “It is intended to emphasize the seriousness of the violations and inform you of the actions that must be taken to ensure that you practice pharmacy in a safe and skilled manner.”
Abu-Hallawah’s corrective action was to ask his employer, Fred Meyer, to provide its pharmacies with references in veterinary dosing and indications.
A state investigator, consulting The Merck Veterinary Manual that he found online, confirmed that the dose of diazepam prescribed by the veterinarian was appropriate for the species. Due to differences in metabolism and depending on the medication, a dog may require a different amount from a person of comparable size.
The case is not the first in which a pharmacist schooled exclusively in human pharmacology — as is true of almost all pharmacists — stumbled when presented with a prescription for a veterinary patient. In veterinary circles, many practitioners have relayed experiences of pharmacists changing prescriptions and substituting medications inappropriately due to ignorance.
However, VIN News Service research suggests that the Washington case is one of the first such incidents to lead to a formal complaint and to result in a reprimand by pharmacy regulators.
More typically, veterinarians learn about an incident long after the fact; lack critical details if the interaction occurred between the pet owner and pharmacist; or are reluctant to complain to authorities about another health professional.
Dr. Maggie Spath, the practitioner in Tacoma who filed the complaint against Abu-Hallawah, said she wouldn’t have involved regulators either, but for the fact that she found the pharmacist unrepentant and unreceptive.
“If he hadn’t been so rude and unwilling to consider that he had made an error, I know I never would have made a formal complaint,” she told the VIN News Service. “He just left me feeling like he wouldn’t listen to me, but I felt so strongly that someone needed to make him listen.”
For his part, Abu-Hallawah said he couldn’t discuss the matter productively with Spath because she was angry. “She just wanted a yelling match, or an insulting match,” he said in an interview. “Like, who’s in charge, or who has more power than the other person. I wasn’t ready to let anybody … insult me in any way.”
The incident involved a 6-year-old, 97-pound Chesapeake Bay retriever named Roo who underwent knee surgery to repair a ruptured cruciate ligament.
The complaint, obtained by the VIN News Service with associated documents through a public-disclosure request to the Washington Department of Health, gives this account:
On Sept. 13, 2012, the day after the operation, Spath prescribed diazepam for Roo to help calm him so his knee could heal properly. Believing that the dog was exhibiting separation anxiety, she chose diazepam to counter the anxiety. As the clinic did not have tablets big enough for a dog of Roo’s size, Spath called in the prescription to a pharmacy chosen by the owner. That was the Fred Meyer at 4505 S. 19th St. in Tacoma.
The prescription was for 60 10-mg tablets of diazepam, with instructions to give two to four tablets every eight to 12 hours as needed.
Clinic records show the prescription was called in during business hours. But by the time the prescription came to the attention of the dispensing pharmacist, Abu-Hallawah, the clinic was said to be closed. In his statement to investigators, Abu-Hallawah said, “I tried to contact the vet to verify directions but it was late already.”
Roo’s owner, Kourtney Ott, stopped by the pharmacy that evening to pick up the medication. In a witness statement, she wrote:
“The pharmacist told me then that the dose was too high. In fact, high enough a dose ‘to kill a human.’ I was confused and frightened and asked what to do?! He told me to cut the pills into fourths and give my dog ¼ at a time. The pharmacy assistant ringing me up told me I probably didn’t need the amount of diazepam and I could wait [while] they cut the prescription in half. (At this point, I barely wanted the prescription but I didn’t know what else to do, my dog needed something to calm him after his surgery.) I sat and waited while my prescription from Dr. Spath was reduced to 30 instead of 60. I went home, did what the pharmacist told me to (give ¼ of a pill) and no changes in behavior were noticed.”
Abu-Hallawah, in an interview with the VIN News Service last week, said Ott misinterpreted his comments. “It was all about customer perception; it wasn’t anything I said. A customer interpreted something in a certain way, and that’s what caused the whole allegation,” he said.
In his statement to investigators, Abu-Hallawah said he told the dog owner that “I don’t have enough resources to calculate the dose for a dog. My resources in the pharmacy all deal with human doses. ... the patient asked me what are the side effects of the medication. I told her for humans the dose is high and I highly recommend you to contact the vet as soon as possible to make sure you are giving the dog the dose needed. Meanwhile, follow the prescription directions on the bottle …”
Abu-Hallawah’s lawyer, Ronald J. Friedman, stated in a letter dated March 19 to the Department of Health that his client “never told the owner to use a lesser dose or that the subject dose would ‘kill the dog.’ ”
Ott told the VIN News Service that she’s certain the pharmacist told her the prescribed dose could be lethal in a person and insinuated that the veterinarian had made a mistake. Whatever was said and heard, the upshot is that Roo’s owner came away from the drug store fearful of the medication.
Even after she verified with Spath, the veterinarian, that the amount prescribed was safe for Roo, Ott felt doubtful. “I was scared to death to use that Valium; I didn’t know who to believe,” she said. Ott said she never did give her dog a full dose. Consequently, Roo, whom Spath described as “rambunctious,” did not stay off his leg.
“On the third or fourth day, he’s limping,” Ott said. “Long story short, I should have done what the vet said.”
The retriever ended up having to have two more operations — the last by a specialist in orthopedic surgery. One year and $8,000 later, Ott said, Roo finally is on the mend.
While she doesn’t attribute all of his difficulties to the pharmacy dispute, she believes it played a role. “If he had been properly sedated (from the start) and the miscommunication and the contradiction between the pharmacist, me and the vet (had not occurred) … I think he would have been healed in five or six months,” Ott said.
She added: “I learned a big lesson. … I won’t ever get a vet prescription from the pharmacy again.” Not even, she said, if it means paying more.
During the course of the state Department of Health investigation, officials proposed sanctions that would have placed Abu-Hallawah on probation for two years; required eight hours of continuing education in pharmacy law and ethics; assigned him to draft a Health Quality Assurance Plan and to write a report on informational resources available on veterinary dosing; and had him reimburse the state the nearly $1,900 it spent to investigate the complaint.
Ultimately, however, a panel of the Board of Pharmacy reviewing the case opted to issue a notice of correction, which involves no enforcement follow-up.
Jack Bucknell, a supervising staff attorney to the board, told the VIN News Service that such notices generally “are used in instances when the violation includes no or minimal patient harm and low risk of future harm. It’s a single occurrence or isolated occurrence … the respondent doesn’t usually have a disciplinary history, and the person in the course of the investigation accepts responsibility for the violation and is or was willing to correct the violation. There’s some information we’ve received that there’s self-remediation that fits into the acknowledgment of the error.”
Bucknell added, “It’s not disciplinary action, but it’s a way to sort of document it so if this thing occurred again, we’d probably make sure that this wouldn’t happen again with this individual.”
Abu-Hallawah’s attorney, in his letter to the department, had requested leniency due to “collateral consequences … unique to Mr. Abu-Hallawah.” He explained that Abu-Hallawah, 31, is a native and citizen of the country of Jordan, living in the United States with his wife and two children as a professional worker sponsored by his employer.
His lawyer, Friedman, stated that any negative conditions placed on Abu-Hallawah’s pharmaceutical license, including probation, could lead to him and his family being deported. “This would be an extraordinary penalty considering the events at issue,” he wrote.
Bucknell, the Department of Health lawyer, said Abu-Hallawah’s personal circumstances would not have influenced the board’s decision. “The real focus would be on patient harm, risk of future harm, remediation and acceptance of responsibility,” he said.
Spath, the veterinarian who filed the complaint, expressed disappointment that Abu-Hallawah wasn’t formally disciplined, but said she would not want him to be deported and that the experience of being investigated may have had impact enough. “I feel like he went through the wringer a little bit,” she said. “I was happy to hear he didn’t lose his license. I didn’t want that. I just wanted him to listen to someone and hopefully learn that animals are not small humans when it comes to pharmaceuticals.”
Abu-Hallawah said he and the pharmacists under his supervision now are especially watchful when it comes to veterinary prescriptions. He said they are given the discretion to decline to fill a veterinary prescription if they’re uncomfortable with it. “They’re pretty aware of what I went through, so they’re being pretty cautious about it,” he said.
Abu-Hallawah acknowledged that he had no training in school or through his employer in veterinary pharmacology. “Nobody does,” he said. He added, “I highly recommend the schools to start (teaching the subject).”
In addition to a pharmacy license, Abu-Hallawah has a pharmacy preceptor license, which authorizes him to instruct interns. Asked whether he teaches anything regarding veterinary pharmacology to his trainees now, Abu-Hallawah replied that his advice is to double-check dosing “so that if anything happens, you cover yourself.”
In sum, he said, “Look it up, write it down on the prescription and if you have any concern, you can always call the vet.”
At Fred Meyer Stores, Marc Cecchini, vice president and director of pharmacy, confirmed through a spokeswoman that all pharmacies in the chain have been provided with veterinary pharmacology references. Fred Meyer operates 133 stores in Washington, Oregon, Alaska and Idaho.
Fred Meyer Stores is a division of The Kroger Co., which describes itself as “the largest traditional grocery retailer in the United States,” with 2,424 supermarkets in 31 states. According to the company 2012 Fact Book, Kroger is the fifth-largest pharmacy operator in the country in number of locations, with retail pharmacies in more than 1,948 of its food stores.
A page on Kroger’s website promotes its pharmacies’ pet medication offerings. Whether all Kroger pharmacies now provide veterinary-drug resources for their pharmacists is unclear. Kroger director of media relations and corporate communications, Keith Dailey, did not respond to multiple email and telephone inquiries.
VIN News Service commentaries are opinion pieces presenting insights, personal experiences and/or perspectives on topical issues by members of the veterinary community. To submit a commentary for consideration, email firstname.lastname@example.org.
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