Ms A noticed the change in colour of her tablets and asked the pharmacist about the issue, who was "unable to recall how the error had occurred", the report said.
Later that year, Ms A returned to the pharmacy three times and was dispensed the correct medication - but with the wrong dosage instructions on the label.
The two pharmacists in the case, known as "Mr B" and "Ms C' in the report, also failed to complete incident forms in a timely manner, did not keep a record of amendments to the pharmacy's records and failed to comply with professional standards, the commission found.
"The number of errors relating to one consumer...is of significant concern," the commission said.
"While each of these errors in isolation might appear relatively minor, any one of the errors could have had serious consequences in different circumstances.
"One of the pharmacists said the errors were made while the pharmacy was busy and he was in a hurry - a "poor explanation", the commission found.
"A pharmacist should never compromise patient safety and professional obligations.
"I accept that pharmacies have busy times; however, in my view, it is the responsibility of the pharmacist to have strategies in place to ensure that patient safety is not compromised.
"The pharmacy was also found to be partly at fault, with the number of errors indicating a "systematic problem".
The deputy commissioner recommended the pharmacy review its operating procedures, conduct a training session for its staff and apologise to the woman involved.
Pharmacists Mr B was also referred to the Pharmacy Council of New Zealand to consider whether he should undergo a competency review.NZME lp ml
