A woman's fertility procedure had to be abandoned because she was taking the wrong medication, owing to a mistake by a pharmacist.
Deputy Health and Disability Commissioner Theo Baker found the pharmacist had breached the code of patients' rights.
The woman was scheduled to have embryos transferred into her uterus as part of in-vitro fertilisation treatment. In preparation she was prescribed a medication called oestradiol valerate.
The prescription was faxed to a pharmacy, where a pharmacist entered the first four letters, "oest", into the pharmacy computer system to produce a label.
The medication name "oestriol" came up on the screen and the pharmacist, in error, selected this and dispensed it to the woman.