Manitoba · College of Pharmacists of Manitoba

Remediation and reflection for Manitoba pharmacists

CPhM tells you exactly what it weighs in a medication-error case: the error, the contributing factors, the level of practice — and your accountability and self-reflection. Three of those are fixed by the time a complaint lands. The fourth is the one you can still change, and it is what a remedial censure turns on.

First: the CPhM is not an RHPA college

Unlike Manitoba’s doctors and nurses, pharmacists are not yet regulated under The Regulated Health Professions Act. CPhM regulates under The Pharmaceutical Act (C.C.S.M. c. P60) and the Pharmaceutical Regulation, which have their own committees, language and deadlines. CPhM regulates pharmacists, pharmacy technicians, interns, students, pharmacies and pharmacy owners. (A move to bring pharmacy under the RHPA is in planning, but the Pharmaceutical Act governs today.) Everything below is CPhM’s process.

Why remediation decides a CPhM outcome

Look at the Complaints Committee’s options: dismiss, resolve informally, censure, impose conditions, suspend, or refer to discipline. The good end of that range is built for a pharmacist who has taken accountability and changed their practice. The censure itself is defined as remedial and educational, and it requires you to accept accountability and acknowledge that your practice needs to change. A pharmacist who arrives having already done that work is speaking the Committee’s own language; one who is still defending the indefensible invites a referral.

Insight comes before certificates

A stack of continuing-education certificates attached to a defensive letter evidences nothing. What CPhM is testing — in its own words, your accountability and self-reflection — is insight. That means being able to say, plainly and unprompted:

• What happened, without minimising it.
• Why it happened — the real causes, including workflow, workload and your own checks, not one at the expense of the others.
• What it meant for the patient, from their side.
• What you have changed, specifically.
• How you know it worked — the evidence, not the intention.

Compare: “I have done a medication-safety module” is an activity. “I missed the interaction because I overrode the software alert under volume pressure; I have changed how our team handles alerts, introduced an independent double-check for high-alert drugs, and audited three months of overrides to prove it” is insight. The Committee sees the difference at once.

Match the remediation to the concern

• Dispensing or medication error → medication-safety CPD, a workflow or double-check change, and an audit of the relevant step (overrides, high-alert drugs, LASA look-alikes).
• Documentation or the patient profile → documentation CPD and a before-and-after audit of your records against the standard.
• Narcotics and controlled drugs → this is the highest-risk category. Tighten and document your accountability and reconciliation processes, and treat any accuracy or diversion concern with the utmost seriousness.
• Scope, clinical knowledge or judgment → targeted CPD in the specific area, a preceptor or mentor, and a case audit.
• Communication, consent or boundaries → communication or boundaries CPD, and a demonstrable change in practice.
• Health, capacity or substance use → take health and legal advice early; treatment and monitoring evidence, properly documented, is the substance here.

Written reflection that stands up

Write it in the first person, keep it short, and make it about your case, not pharmacy in general. Facts, causes, effect on the patient, changes, evidence — in that order. Then avoid the four failures the Committee spots immediately:

• Blaming the workload or the technician alone. Understaffing and volume may be real, but the professional responsibility for the check sits with you.
• Blaming the patient or the prescriber. It reliably makes the outcome worse.
• Regret without change. CPhM knows errors are distressing; it is looking for what you did next, not how sorry you are.
• Writing what you think they want. A pharmacist panel and a public member recognise a performance, and it discredits the rest.

Evidence the Committee can weigh

• Dated CPD certificates, showing the work was done while the file was open.
• A signed, dated reflective statement.
• Audit data — the before-and-after numbers on the step that failed.
• A new checklist, protocol or workflow change you have introduced.
• A letter from the pharmacy manager or a mentor confirming the change in your practice, not merely praising you.

If the Committee is weighing a censure, this bundle is what makes it available — and, if the matter is referred to discipline, remediation and a joint position on penalty are central to what the Discipline Committee orders.

After a censure, conditions or discipline

If you accept a censure, treat its practice-change and education requirements as commitments to complete and evidence — and remember it may now be published under s.36(2), so what you can show you did about it matters. If the Discipline Committee has imposed conditions, a course of study, a preceptor or treatment, documented compliance is the route back and the basis for eventually lifting them. Discipline decisions are published and recorded on your profile; your remediation is the part of that record you still control.

Look after yourself while this runs

CPhM openly recognises the collateral effect a complaint and a medication error have on the pharmacist — take that seriously for yourself. Lean on trusted colleagues, use any employee or member assistance program available to you, and speak to your own physician. A pharmacist who is not coping does not remediate well, and does not write the calm, fact-driven response CPhM is looking for.

This guide is general information about the College of Pharmacists of Manitoba (CPhM) and is not legal advice. Regulatory processes turn on their facts, and The Pharmaceutical Act, the Pharmaceutical Regulation and CPhM by-laws change. Take advice from a lawyer experienced in Manitoba pharmacy regulation before you respond to CPhM, and notify your professional liability insurer. Note that CPhM may contact you directly without going through your lawyer — keep your lawyer informed of every communication. Healthcare Ethics Courses is an independent CPD provider and is not affiliated with CPhM. Last updated July 14, 2026.