Winnipeg pharmacist fined for dispensing incorrect dosage of anti-psychotic medication

A Winnipeg pharmacist has been fined for misconduct after dispensing a mistakenly high dose of an anti-psychotic, harming her patient.

Rumina Ishani was fined $3,500 and ordered to pay $5,000 in costs by the College of Pharmacists of Manitoba earlier this month, after pleading guilty to professional misconduct.

The college, in a written disciplinary decision, said the incident occurred on Aug. 12, 2025, at the Marion Street Shoppers Drug Mart where Ishani worked at the time.

She filled an aripiprazole prescription for a patient that day. The patient had first been given the anti-psychotic at that pharmacy in November 2023 at two milligrams a day for 30 days, and was again prescribed the drug in February 2025 at one mg/day, which was increased to two mg/day in March.

The patient filled her prescription monthly from then on.

On Aug. 12, the pharmacy received the patient’s prescription for the same dosage, but a pharmacy assistant who was entering data mistakenly put 20 mg as the dose.

Ishani did not notice that the wrong strength had been selected, the disciplinary decision said.

“Ms. Ishani admitted that she did not scrutinize the drug utilization review or transaction notes appearing on the patient’s prescription order when she performed the data verification step or when she performed the clinical verification step,” reads the decision.

“Had she done so, she would have seen that there were drug interactions relevant to the aripiprazole prescription and another medication being dispensed to the plaintiff and that the dosage had been changed significantly from previous fills.”

The patient said she did not receive any counselling from the pharmacist about the use of the prescription, though Ishani said she had. Ishani said she had not confirmed the age of the patient and that she mistakenly thought an adult who was with the patient, a family friend, was who the drug was prescribed to.

The pharmacy’s manager told the college the error should have been caught when Ishani was to counsel the patient about the use of the drug and that the dose change would have been flagged in the pharmacy’s system with a flag that the prescription was new or had been changed.

“During the counselling provided on the prescription, Ms. Ishani failed to correctly identify the patient and failed to identify the dose change and drug therapy problems, despite this information being present and visible on the computer counselling screen,” reads the decision.

The patient took a 20mg pill on Aug. 13 and was excessively drowsy throughout the day, then a second pill on Aug. 14, after which the patient got nauseous and vomited up the pill.

Someone noticed that the pill bottle was labelled 20 mg rather than two mg and called poison control. The patient was taken to a hospital, where they made a full recovery.

The college found that Ishani had three opportunities to recognize the error: at the prescription verification step, at the product check and at the patient counselling step.

“Her sequence of failures to catch the mistake resulted in patient harm. Dispensing the incorrect strength of aripiprazole put the patient at risk of experiencing adverse effects of the drug and adverse effects from drug interactions and ultimately caused the patient’s hospitalization,” reads the decision.

“It is fortunate that the harm was not worse.”

Ishani got her pharmacy degree in the United States in 1991 and worked as a licensed pharmacist in Ontario from 1992 and 1997, then was a stay-at-home mother until 2008, when she returned to practice in Ontario. Ishani began practicing pharmacy in Manitoba in 2023.

She has no prior disciplinary history in Manitoba, but did receive two cautions from the profession’s regulator in Ontario.

The college said Ishani has not attempted to minimize her errors or deflect responsibility and has demonstrated an intention to improve her practice.

erik.pindera@winnipegfreepress.com