Pharmacist Issued Warning After Dispensing Buprenorphine Instead of Emergency Contraceptive
Date of Decision: December 3, 2025
Registrant's Role: Pharmacist
Allegations:
- Incorrectly dispensed Espranor (buprenorphine), a Schedule 3 Controlled Drug, instead of the prescribed EllaOne tablet.
- Failed to conduct proper identity checks prior to dispensing.
- Did not explain the potential side effects of the incorrect medication or provide safety netting.
- Failed to report and escalate the incident in line with duty of candour and GPhC standards.
Outcome: Warning issued and published 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, assess risks in the care they provide, and do everything possible to minimise them.
Case Summary
Allegations
This case revolves around a serious dispensing error made by the registrant, a Responsible Pharmacist, on 7 December 2024. The pharmacist erroneously provided Espranor (a buprenorphine formulation), a Schedule 3 Controlled Drug used in the management of opioid dependence, to a patient who had been prescribed EllaOne, an emergency contraceptive. Notably, these two medications are neither look-alike nor sound-alike drugs and serve entirely different therapeutic purposes, making this a case of a non-trivial and avoidable error.
The registrant failed to perform appropriate identity checks before handing out the medication. After the patient ingested the incorrect medicine, she began to experience adverse symptoms including sickness, dizziness, and nausea. Emergency medical attention was required, and paramedics administered treatment to manage these symptoms.
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- Full allegations considered by the GPhC
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- Sanctions considered and imposed on the Pharmacist
- Key professional learning points
Original Case Document
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