Two pharmacists have been reprimanded after giving a woman anti-depressants instead of the painkillers she was prescribed.

The 32-year-old was prescribed the painkiller Tramadol, after having a wisdom tooth removed.

But instead of dispensing 30 Tramadol 50mg capsules, the pharmacists mistakenly selected from the shelf 30 fluoxetine 20mg capsules, an anti-depressant (originally branded Prozac).

The woman took 20 capsules of fluoxetine before the dispensing error was discovered a week later.


Fluoxetine has a long list of possible side effects, including a possible increased suicide risk among those already suffering from depression, abnormal heart rhythms, rash and seizures.

Stopping taking the medication abruptly can also cause side effects, and it is not recommended.

According to case notes posted on the Health and Disability Commissioner's website, the fluoxetine capsules had been repackaged at the pharmacy into a plain white box, and mislabelled as tramadol.

The pharmacist became distracted while labelling the packet and did not check its contents, as was required by the pharmacy's standard operating procedures.

Health and Disability Commissioner Anthony Hill released the case notes, which found the two pharmacists in breach of the Code of Health and Disability Services Consumers' Rights.

He said the dispensing was checked by a second pharmacist, who did not identify the error either.

The pharmacy's standard operating procedures required the pharmacists to open the packets to make sure the correct medicine and strength had been selected.

However, the second pharmacist advised that on this occasion, because the strips of fluoxetine capsules are similar looking to strips of tramadol capsules, the medication may not have been removed from the packet for a more thorough check.

Mr Hill was critical of both pharmacists for failing to ensure that the correct medication was dispensed in accordance with the professional standards set by the Pharmacy Council of New Zealand and with the pharmacy's SOPs.

In Mr Hill's opinion, the dispensing error was the pharmacists' alone as the pharmacy had appropriate SOPs in place, as well as a sufficient number of trained staff working at the time.

Mr Hill noted that both pharmacists had apologised to the woman, and he recommended that the pharmacy randomly audit its staff compliance with SOPs over a one month period and report back.