A pharmacist will have his skills re-assessed after giving a woman the wrong prescription, forcing her to go to hospital while on an overseas holiday.
The woman was prescribed medication to lower the risk of blood clots and prevent deep vein thrombosis before an overseas trip, but the pharmacist incorrectly dispensed drugs to treat severe anaemia.
The pharmacist did not notice, even though the label did not match the prescription.
The woman had previously had a life threatening deep vein thrombosis, and was concerned about blood clots forming while flying.
One the day of her flight the woman injected herself twice with the drugs, but the following day felt unwell and found her legs covered in bruises and she was admitted to hospital, according to a complaint to the Health and Disability Commissioner.
It wasn't until two weeks later that the pharmacist discovered his error and contacted the woman, who was still travelling.
Commissioner Anthony Hill found the pharmacist alone was responsible for the mistake, noting there were physical differences between the two drugs, their packaging and the fact one was stored in a fridge and the other on a shelf.
He recommended an assessment on processing prescriptions.
The pharmacy has since changed its processes for dispensing drugs.