New Hampshire Code of Administrative Rules Ph - N.H. Pharmacy Board
Case 1: Dispensing Error Due to Inadequate Verification Procedures
Situation
A community pharmacy dispensed metoprolol 100 mg instead of metoprolol 25 mg to an elderly patient. The pharmacist was working alone during a busy shift and skipped the final verification step.
Relevant Ph Rule Concepts
Pharmacists must ensure accurate dispensing
Pharmacies must maintain adequate staffing and workflow
Mandatory final check by a licensed pharmacist
Board Findings
The pharmacy lacked a formal verification process
No documentation of a second check or barcode scan
High workload without relief staff was a known issue
Outcome
Pharmacist required to complete continuing education in medication safety
Pharmacy ordered to revise SOPs
Written warning placed on the pharmacist’s license record
Key Lesson
Under Ph rules, workload is not a defense. Patient safety overrides operational pressure.
Case 2: Improper Compounding Practices in a Retail Pharmacy
Situation
A pharmacy compounded dermatological creams without:
Valid patient-specific prescriptions
Proper beyond-use dating
Required documentation
Relevant Ph Rule Concepts
Non-sterile compounding must follow USP standards
Compounding without prescriptions may be classified as manufacturing
Documentation and labeling are mandatory
Board Findings
Compounded products prepared in advance
No master formulation records
Lack of training documentation for compounding staff
Outcome
Immediate cease-and-desist order
Monetary administrative fine
Mandatory inspection before resuming compounding
Key Lesson
Ph rules strictly separate compounding vs. manufacturing. Crossing that line triggers serious penalties.
Case 3: Controlled Drug Inventory Discrepancies
Situation
During a routine inspection, inspectors found repeated shortages of Schedule II opioids with no DEA Form 106 filed.
Relevant Ph Rule Concepts
Accurate controlled drug inventories
Immediate reporting of theft or loss
Secure storage requirements
Board Findings
Poor perpetual inventory system
Delayed discovery of losses
Inadequate access controls
Outcome
Pharmacist-in-charge (PIC) disciplined
Required implementation of electronic tracking
Referral to DEA for review
Key Lesson
Under Ph rules, failure to detect loss is itself a violation, even without proof of diversion.
Case 4: Unlicensed Personnel Performing Pharmacy Functions
Situation
A pharmacy technician allowed a cashier to:
Count tablets
Print prescription labels
Retrieve medications from stock
Relevant Ph Rule Concepts
Clear separation of duties
Only licensed or registered individuals may perform pharmacy tasks
Pharmacist supervision requirements
Board Findings
No technician registration on file
PIC failed to enforce role boundaries
Repeated practice over several months
Outcome
Suspension of technician registration
PIC placed on probation
Mandatory staff retraining
Key Lesson
Ph rules place direct responsibility on the PIC for staff actions, even if delegated.
Case 5: Failure to Counsel Patients Properly
Situation
Multiple patients reported never being offered counseling on new prescriptions, including anticoagulants.
Relevant Ph Rule Concepts
Mandatory offer to counsel
Documentation of refusal
Special emphasis on high-risk medications
Board Findings
No counseling logs
Drive-through workflow bypassed counseling
Language access not provided
Outcome
Formal reprimand
Policy revision requirement
Random compliance audits ordered
Key Lesson
Under Ph rules, “offer to counsel” must be active and documented, not assumed.
Case 6: Pharmacist Practicing While Impaired
Situation
A pharmacist was reported for appearing intoxicated during a shift.
Relevant Ph Rule Concepts
Fitness to practice
Duty to self-report impairment
Employer reporting obligations
Board Findings
Confirmed alcohol impairment
Prior unreported incidents
Risk to public safety
Outcome
Immediate suspension
Mandatory enrollment in a monitoring and recovery program
Conditional reinstatement
Key Lesson
Ph rules prioritize public protection over punishment, but impairment is treated as a critical violation.
Case 7: Pharmacy Operating Without a Valid License
Situation
A pharmacy continued operations after its permit expired due to administrative oversight.
Relevant Ph Rule Concepts
Annual licensure renewal
Display of valid permit
Responsibility of ownership and PIC
Board Findings
Pharmacy operated unlicensed for 23 days
Prescriptions dispensed during that time
No internal compliance check system
Outcome
Civil penalty
Retroactive review of prescriptions
Compliance audit ordered
Key Lesson
Licensure is not automatic. Ph rules require active compliance monitoring.
Overall Themes of NH Ph Rules
Patient safety is the primary goal
Pharmacists are personally accountable
Documentation is as important as the act itself
PIC carries enhanced responsibility
“I didn’t know” is not a defense
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