Designated Manager – Professional Supervision of Pharmacy Personnel


Published: June 2011

Review Date: 2014

Legislative references:

College Contact: Pharmacy Practice


To clarify the obligations of the designated manager (DM) with respect to the supervision of pharmacy personnel.


As defined in the Drug and Pharmacies Regulation Act, 1990 (DPRA) the DM is the pharmacist designated by the owner of the pharmacy, in information provided to the College, as the pharmacist responsible for managing the pharmacy. The DM is a pharmacist in Part A of the register who is responsible for the human resources management in a pharmacy, including the supervision of both professional and lay staff. Part B pharmacists are permitted to supervise registrants in hospitals or health care facilities as managers; however, they remain ‘non-practicing’ pharmacists.

The DM’s responsibilities are equal to that of the person, or the directors of a corporation, who have been issued a certificate of accreditation to ensure that the pharmacy conforms to the requirements set out in legislation and regulations. Where a panel of the Accreditation Committee believes a DM has contravened the provisions of the DPRA, the Committee may refer allegations of proprietary misconduct against the DM for breaches of the DPRA to the Discipline Committee which can make a finding of proprietary misconduct against the DM.

The DM has the same professional practice obligations as all registered pharmacists, and in addition to these, the DM has authority and accountability over decisions affecting the operation of a pharmacy. It is the responsibility of the DM to effectively oversee the day-to-day management of the pharmacy, including all aspects of the operation of any remote dispensing location(s) permitted through the certificate of accreditation. The DM’s human resources responsibilities are both functional and strategic. For example, not only must the DM establish job descriptions and a performance measurement and improvement system for pharmacy employees, but the DM must also ensure that, at all times, staffing in the pharmacy supports the pharmacist(s) in their cognitive and patient care functions.

Where the certificate of accreditation permits the operation of a remote dispensing location that is a dispensary staffed by a pharmacy technician, the DM will ensure the technician and lay staff, if any, are appropriately and effectively supervised.As inter-professional care expands, this responsibility includes ensuring that the pharmacist has sufficient support to collaborate as needed with other health professionals. The regulation of pharmacy technicians creates additional opportunities for intra-professional collaboration according to the scope of each registrant’s practice.

  1. Patient care is provided according to evidence-based practices;
  2. Staffing and workflow in the pharmacy are arranged in such a manner as to enable registrants to maintain the accepted standard of pharmacy practice, and to deliver safe and effective patient care;
  3. Staff members are provided with the appropriate tools and resources required to deliver safe and effective patient care; and
  4. The delivery of patient care within the pharmacy is continuously evaluated through a quality improvement process during which errors are detected and corrected and practice improvements are initiated.

Safe Medication Practices

Safe medication practices prevent and reduce medication errors through established policies and procedures and continuous quality improvement. Components of a safe medication practice include providing:

– access to current medication information
– systems to identify high alert medications and
– procedures to store, count, administer, and dispose of medications.

Wherever possible, an independent double check is used to verify products against prescriptions, and to check repackaged and labeled medications and volumes for reconstituted preparations prior to release.

Remote Dispensing Location

A remote dispensing location means a premises where drugs are dispensed or sold by retail to the public and that is operated by, but is not at the same location as, a pharmacy whose certificate of accreditation permits its operation.

Risk Assessment and Management

Risk assessment and management systems are those which provide a structured approach to identifying and managing errors associated with an area of practice that is high risk and, therefore, has a greater potential for patient harm. Examples of high risk practices include compounding, dispensing methadone, high volume dispensing, and dispensing blister packs; these are all practices that may be associated with a greater than normal risk to patient safety.

Medication Incident

A Medication Incident is defined as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the care and control of the registrant.


The DM is responsible for the overall operation of a pharmacy including supervision of staff, facilities, equipment, and supplies. A pharmacist must be on duty at all times that the pharmacy is open. Where a pharmacist is not physically present in a remote dispensing location, the pharmacist must be physically present in the pharmacy that operates the remote dispensing location in order to permit live two-way communication with the patient through an audio-visual link.

Regulated health professionals are responsible for their own practice within legal requirements and ethical principles. The DM ensures that only registrants perform the controlled acts of dispensing, selling, or compounding a drug, and supervising the part of a pharmacy where drugs are kept, according to the terms, conditions, and limitations imposed on his or her certificate of registration. As specified in the DPRA, the DM, along with the owner of the pharmacy, is accountable for any offence against the Act committed by pharmacy staff members when carried out with the DM’s or owner’s permission, consent or approval, whether express or implied.

The DM is responsible for ensuring that delegation protocols within the pharmacy are in compliance with College policy on the delegation of controlled acts. The DM ensures that, where the practice of a controlled act is delegated by one registrant to another, it is done according to the terms, conditions, and limitations of each registrant’s certificate of registration.

The DM will support safe medication practices within the pharmacy through the development of policies and procedures to ensure that clinically relevant information that impacts patient care is immediately available to appropriate staff members, including drug recalls, advisories, and warnings. The DM will ensure that an appropriate risk assessment and management system is in place to mitigate risks to patient safety and to prevent medication incidents.

A pharmacy is a health information custodian as defined in the Personal Health Information Protection Act, 2004. The owner of the pharmacy is ultimately accountable for the personal health information collected and retained within the pharmacy, including with respect to a remote dispensing location if any; however, the DM has the responsibility to ensure the pharmacy practice meets the requirements of legislation and regulation. The DM must ensure that the appropriate policies and procedures required to use, protect, store and dispose of personal health information are in place and that staff receive training on their duties in this regard. The DM is responsible to ensure that the appropriate record retention schedules are in place and that back up and recovery systems are maintained according to legislated standards.

In managing and supervising professional staff members, the DM will take measures to restrict the practice of an incapacitated and/or incompetent registrant to protect public safety. Where such measures are taken, the DM will document his or her observations, the steps taken to restrict the practice of the registrant, and any support given to the registrant to recover capacity. The DM will file a mandatory report to the College.

Mandatory Reporting

Regulated Health Professions Act, 1991 A member (registrant) is legally obligated to file a mandatory report in several circumstances including:

  • If they have terminated the employment of a regulated health professional for reasons of professional misconduct, incompetence or incapacity;
  • Where restrictions are imposed on a registrant’s practice for reasons of professional misconduct, incompetence or incapacity; and
  • Where a person intended to terminate employment, but they did not do so because the regulated health professional resigned.

Health Professions Procedural Code For the purpose of the Code (Schedule 2 of the RHPA) sexual abuse is defined as sexual intercourse or other forms of sexual relations between the member (registrant) and the patient; touching of a sexual nature, of the patient by the member (registrant), or behaviour or remarks of a sexual nature by the member (registrant) towards the patient.

A registrant is required to file a report in writing with the Registrar if they have reasonable grounds, obtained in the course of practicing their profession, to believe that a member (registrant), of the same or different college has sexually abused a patient. The report must be made within 30 days and may only include the patient’s name where written consent has been given by the patient or, if the patient is incapable, the patient’s representative. The report must include the name of the registrant filing the report, the name of the member (registrant) who is the subject of the report and an explanation of the alleged sexual abuse.

Occupational Health and Safety Act, 1990 The DM shall notify the owner of any incidents causing illness, injury, or death in the workplace to assist the owner to make the required mandatory reports

Child and Family Services Act, 1990 Section 72 of the Act states that the public, including professionals who work with children, must promptly report any suspicions that a child is or may be in need of protection to a children’s aid society (CAS). The Act defines the phrase “childin need of protection” and explains what must be reported to a CAS. It includes physical, sexual and emotional abuse, neglect, and risk of harm.