Decision discussed: Pharmaciens (Ordre des) c. Zalat, 2025 QCCDPHA 23
When pharmacists dispense high-risk medications, the legal expectations are uncompromising: the patient must receive clear, complete, and safe counselling, even when confidentiality, logistics, or awkward family dynamics get in the way. The recent Quebec disciplinary ruling in Zalat is a strong reminder that a pharmacist’s duty to counsel is non-delegable, and trying to “work around” barriers can lead straight to professional misconduct.
What Happened in the Zalat Case
In Zalat, a pharmacist dispensed a corrosive chemical treatment (trichloroacetic acid 50–90%) to a patient’s mother without counselling the actual patient. She was worried about breaching confidentiality because the medication would reveal an ITSS diagnosis. The mother insisted the patient already knew how to use it, a statement that turned out to be false.
The patient later used the product incorrectly and suffered a chemical burn. The tribunal found the pharmacist negligent, even though:
- She was genuinely trying to respect confidentiality
- The mother and patient misled her
- The situation was logistically difficult
- The pharmacist acted in good faith
The message from the tribunal was clear: good intentions are not a defence when patient safety is at stake.
Why This Decision Matters for Pharmacists
1. If you cannot safely counsel the patient, you cannot dispense the medication.
The tribunal emphasized that the duty to counsel is a core element of the pharmacist’s professional responsibility. High-risk medications, especially corrosive or hazardous compounds, require direct, unambiguous counselling.
If you cannot reach the patient, if the patient refuses counselling, or if counselling creates a confidentiality conflict, the pharmacist must pause, not improvise.
2. Confidentiality does not override the duty to prevent harm.
This case is a perfect example of conflicting duties. The pharmacist tried to avoid revealing sensitive information to a parent. But confidentiality cannot justify incomplete counselling. The tribunal made the hierarchy clear:
Patient safety comes first. Full stop.
3. You cannot rely on third-party assurances.
Parents, spouses, roommates, adult children, and friends often pick up medications. But their assurances, “she knows what to do,” “he’s used it before,” “I’ll explain it to him”, do not satisfy the pharmacist’s legal obligations.
Critical communication cannot be outsourced.
4. Patient misconduct doesn’t protect the professional.
Even though the mother and patient lied about their knowledge and circumstances, the pharmacist remained fully accountable. Tribunals consistently hold that:
- Professionals control the environment
- Professionals bear responsibility for risk management
- Patients’ statements cannot replace professional judgment
This trend exists across many regulated professions, not just pharmacy.
The Bigger Regulatory Trend
The Zalat decision reflects a broader pattern in Canadian professional discipline: regulators now focus not only on what happened, but what the professional failed to prevent. The standard of care requires anticipating foreseeable risks, especially when dealing with dangerous treatments.
The tribunal effectively said:
- If the situation feels “off,” pause.
- If counselling can’t be done safely, don’t proceed.
- If confidentiality prevents counselling, don’t guess — find another path.
Practical Takeaways for Pharmacists
- Always speak to the patient when the medication carries significant risk.
- Document every counselling attempt and communication barrier.
- Do not dispense if you cannot counsel without breaching privacy.
- Offer alternatives, such as contacting the prescriber, scheduling a private call, or asking the patient to come in.
- Never rely on a family member’s instructions, assurances, or claims of prior experience.
Conclusion
The Zalat decision delivers a clear message: pharmacists must prioritize patient safety above convenience, assumptions, and even confidentiality challenges. When duties collide, the safest course of action, legally and ethically, is to pause, reassess, and ensure the patient receives proper counselling before dispensing high-risk treatment.
For regulated professionals who often operate in complex and imperfect conditions, Zalat is an important reminder that your duty of care cannot be delegated, diluted, or deferred.
Contact Tamir Litigation Law Firm today at 416-499-1676 or visit tamirlitigation.com to learn how you can protect your licence and your reputation. You can also message us on WhatsApp for a free initial chat.