Amlodipine Supplied Instead of Amitriptyline Results in Severe Patient Harm and No Pharmacist Sanction

Allegations

This case involved a significant dispensing error that had considerable adverse consequences for a patient. On 30 June 2016, while working as the Responsible Pharmacist at a busy community pharmacy, the registrant dispensed Amlodipine 10mg tablets instead of Amitriptyline 10mg tablets. The prescription was for the latter, a tricyclic antidepressant commonly used in migraine prophylaxis, and had been issued electronically by the patient’s GP.

The patient, referred to as Patient A, had undergone recent knee surgery and was managing postoperative recovery when the error occurred. Upon collecting her medication, she did not recognize the difference in packaging and assumed a change in manufacturer. Within days, she experienced a severe migraine, systemic symptoms including high blood pressure, hot and cold sweats, and debilitating nausea and vomiting. Subsequently, she developed alarming bilateral lower limb swelling and discoloration, leading to multiple medical assessments.