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.

The registrant failed to conduct a thorough accuracy check, resulting in the incorrect medication being supplied. This led to the patient experiencing bradycardia, a potentially serious adverse event, and requiring further medical assessment and treatment.

Findings

The GPhC Investigating Committee found that the registrant had not exercised an appropriate standard of care in her professional duties. The error was not a simple oversight but a failure of professional diligence in a high-risk area of practice: final accuracy checking.

While there was no indication of malicious intent or broader systemic misconduct, the Committee highlighted that the registrant did not act in accordance with multiple GPhC standards, including those concerning safe care delivery, professional judgement, and risk mitigation.

The committee concluded that:

“The unavoidable conclusion is that [the registrant] failed to conduct a sufficiently careful accuracy check. The failure led to harm to the patient who consequently suffered from Bradycardia.”

GPhC Determination on Impairment

The panel considered the registrant’s fitness to practise in light of the incident. While the case did not proceed to a full impairment hearing, the Investigating Committee evaluated the seriousness of the breach and its implications for patient safety and public confidence.

The registrant’s actions were not found to be indicative of broader unfitness to practise, but the Committee judged the failure significant enough to warrant formal censure in the form of a published warning. This indicates that while the registrant’s fitness to practise is not currently impaired, the breach nonetheless had real-world consequences and should serve as a deterrent.

Sanction

The sanction issued was a formal warning to remain on the GPhC register for 12 months. The Committee emphasized that any recurrence of similar failings would likely result in more serious regulatory consequences.

The warning reads in part:

“The registrant is warned to ensure all clinical and accuracy checks are completed to a high standard to ensure patient safety and public confidence are assured. Any repetition of the same or similar failings is likely to result in more serious regulatory intervention.”

This is a mid-tier regulatory outcome, signalling that while the registrant is not currently barred from practice, there is a clear expectation for improvement and future vigilance.

Key Learning Points for Pharmacy Professionals

1. Vigilance in LASA Medications: Allopurinol and Atenolol are a classic example of LASA drugs. Pharmacy professionals must be especially vigilant with such pairs. Visual similarity or name confusion can easily lead to dangerous outcomes.
2. Final Accuracy Checks Are Critical: This case highlights the critical nature of the Responsible Pharmacist’s role in final checks. Signing off on a dispensed item carries direct responsibility, and any lapse can have real-world patient safety consequences.
3. Understanding the Consequences of Errors: The patient in this case suffered bradycardia – a condition that could lead to fainting, fatigue, or even cardiac arrest. Pharmacists must be aware that errors in drug dispensing are not abstract risks; they have tangible and sometimes serious consequences.
4. Clinical Familiarity with Medicines Dispensed: A strong grounding in pharmacology allows pharmacists to apply another layer of safety during dispensing. Awareness that Atenolol (a beta-blocker) and Allopurinol (a gout treatment) serve entirely different purposes may have helped catch the error.
5. Proactive Risk Assessment: Standard 9 requires pharmacy professionals to lead in assessing and mitigating risks. This includes double-checking LASA medications, ensuring correct labelling protocols, and fostering a culture where double-checking is encouraged, not rushed.
6. Documentation and Transparency: Although not discussed in depth in this case, the presence of clear documentation and openness about the error likely influenced the decision to issue a warning rather than pursue a fitness to practise impairment case. Prompt reporting and engagement with error investigations are essential.

This case serves as a strong reminder to pharmacists about the importance of accuracy, vigilance, and professional responsibility in safeguarding patient health.

Original Case Document

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