Ms A asked the staff about the difference and it was discovered that in March, she had been given tenoxicam instead of tamoxifen - which was an antirheumatic, anti-inflammatory and analgesic agent.
The pharmacy launched an investigation into the error and found Ms A's prescription was correctly entered into the computer, as a label for 20mg tamoxifen was generated, the report said.
However, tenoxicam 20mg was incorrectly selected from the shelf and subsequently dispensed to her.
The pharmacy's policy at the time was that the dispensing pharmacist must be identified at all times, but in that case, the dispenser had not initialled Ms A's prescription, so it was not known who made the error.
Mr Hill said the pharmacy did not provide services to Ms A with reasonable care and skill and breached her Code of Rights.
"I consider that it was suboptimal that tamoxifen and tenoxicam had been placed in close proximity at the pharmacy without a specific alert or precaution notice attached to the shelf."
It was also poor practice of the pharmacy to not document regular reviews and updates of its standard operating procedures (SOPs), he said.
The pharmacy has since written a formal apology to Ms A, Mr Hill said.
HDC recommendations:
* audit compliance with its SOPs related to consumer safety over a three-month period on three separate days and provide HDC with the outcome of that audit;
* ensure that SOPs and updates of SOPs related to consumer safety are signed by all staff to indicate that they have read and understood the procedures;
* ensure that SOPs are reviewed at least every two years, and that the date of review is clearly documented; and
* ensure that all medications with look-alike sound-alike names stocked in the pharmacy are associated with specific measures to prevent dispensing errors.
