A Winnipeg pharmacist has been fined by her provincial regulatory body after dispensing an antipsychotic medication at 10 times the prescribed dose, an error that resulted in a patient being hospitalized.
Rumina Ishani pleaded guilty to two counts of professional misconduct and displaying a lack of knowledge, skill, or judgment before a Discipline Committee of the College of Pharmacists of Manitoba (CPhM). Following a July 14 hearing, the College’s decision was released on Oct. 8.
The incident occurred on Aug. 12, 2025, at the Shoppers Drug Mart on Marion Street, according to the disciplinary decision. Ishani was filling a prescription for aripiprazole, an antipsychotic medication commonly sold under the brand name Abilify.
The patient’s most recent prescription was for a daily dose of two milligrams. However, a pharmacy assistant that was working with Isahni entered 20 milligrams into the system.
According to the decision, Ishani failed to catch the error at three checkpoints: prescription verification, the product check, and the final patient counselling stage. During prescription verification, she did not review the drug utilization review and transaction notes, which would have flagged the dosage change and potential drug interactions.
Furthermore, Ishani misidentified the patient while providing instructions and mistakenly assumed that an adult family friend accompanying the patient was the patient. She did not check the computer screen to confirm the patient’s age and did not fully complete identity checks, missing another opportunity to detect the error.
The patient took the incorrect 20-milligram dose on Aug. 13, 2025, and experienced severe drowsiness throughout the day, the decision said. After taking a second dose the following morning, the patient experienced nausea and vomiting. Someone who knew the patient checked the pill bottle, discovered the 20-milligram label, and immediately contacted poison control. The patient was taken to hospital and has since made a full recovery.
“This case is a good example of why proper verification and counselling is vital for safe and effective pharmaceutical practice,” the panel said in the decision, emphasizing that pharmacists must exercise rigorous oversight to prevent medication errors.
Under the order, Ishani must pay a $3,500 fine and contribute $5,000 toward the costs of the investigation and hearing. The conviction, penalty, and circumstances of the offence will also be published publicly.
The disciplinary panel noted that Ishani showed genuine remorse, co-operated fully with investigators, and accepted responsibility without attempting to deflect blame.
Ishani graduated from the Massachusetts College of Pharmacy in 1991 and has practised in multiple jurisdictions. She has no prior disciplinary history with CPhM, although regulatory records note two cautions during her practice in Ontario.
