Responsible Pharmacist Issues Wrong Medication: Allopurinol-Atenolol Mix-Up Leads to Patient Harm
Date of Decision: September 4, 2025
Registrant's Role: Pharmacist
Allegations:
- The registrant, acting as Responsible Pharmacist, incorrectly checked and signed off medication.
- A box of Atenolol 100mg tablets was incorrectly labelled and dispensed as Allopurinol 100mg.
- The error led to the patient consuming the wrong medication and suffering bradycardia.
Outcome: Warning issued, to remain on the register for 12 months.
GPhC Standards Breached:
- Standard 1 – Pharmacy professionals must deliver person-centred care and consider the impact of their practice.
- Standard 5 – Pharmacy professionals must use professional judgement to deliver safe and effective care.
- Standard 9 – Pharmacy professionals must demonstrate leadership and assess risks in care provision, keeping risks as low as possible.
Case Summary
Allegations
The case revolves around a serious medication error made by the registrant while performing duties as a Responsible Pharmacist. On 7 May 2024, the registrant checked and signed off a medication intended for Patient A, which was labelled as Allopurinol 100mg. However, the medication actually dispensed was Atenolol 100mg, a significant error given the differing therapeutic indications and risk profiles of these two medications.
Allopurinol is a xanthine oxidase inhibitor used primarily for the treatment of gout and hyperuricemia, while Atenolol is a beta-blocker used for managing cardiovascular conditions such as hypertension and angina. These drugs are classified as LASA (look-alike, sound-alike) medications, meaning that despite having different therapeutic actions, their names and packaging may be similar enough to cause confusion in high-paced dispensing environments.
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- Full allegations considered by the GPhC
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Original Case Document
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