A teenager accidentally took medication for depression, OCD, panic attacks and PTSD for six months instead of migraine medication, thanks to a pharmacist's mistake.
The teenager was meant to have taken sumatriptan for her migraines, but was mistakely given sertraline in August 2019.
The mistake was not picked up until February 2020, when a school nurse noticed the medication pack did not match the label.
Her mother complained to the Health and Disability Commissioner (HDC) soon after.
The mistake was made on the pharmacist's first day, where she undertook a final check of the prescription and medication after it was dispensed.
Referred to as 'Ms B', she told the HDC she had given the teen's mother a verbal apology, reported the mistake to their GP and notified the Pharmacy Defence Association after the school nurse's call.
She said sumatriptan and sertraline, which were then next to each other on the shelf, were separated "far from each other" and a red sticker was put underneath them warning their names were similar.
However, an investigation which was meant to happen was delayed by about four months after Ms B went on leave and then was injured.
The pharmacy did not investigate the error while Ms B was off work.
The teen's mother, dubbed 'Mrs A', said her daughter struggled to take medication after the incident and told the HDC all she had wanted was an apology and empathy.
She told the HDC she felt like she hadn't received either.
Deputy Commissioner Kevin Allan found both Ms B and the pharmacy at fault.
He recommended the pharmacy provide a written formal apology, outline its actions to prevent the mistake from happening again and give refresher training for dispensing and checking medications.
Allan also recommended the pharmacy carry out a random audit on dispensing and checking medications for 20 prescriptions over one month and review any dispensing errors in the last six months.
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