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A pharmacist who mistakenly dispensed a controlled drug used in the management of opioid dependence to a patient who was prescribed an emergency contraceptive has been warned by the General Pharmaceutical Council.

The regulator’s investigating committee heard Fola Mustapha was working as the responsible pharmacist when she dispensed an Espranor tablet (buprenorphine) instead of a prescribed Ella One tablet on December 7, 2024.

The patient suffered sickness, dizziness and nausea after taking the Espranor tablet and needed medical attention. The committee found Ms Mustapha failed to carry out proper identity checks before she dispensed the wrong medication.

She also failed to explain the possible side effects of consuming the wrong medicine to the patient, provide “safety netting” advice after the error had been discovered and report and “escalate” the incident to the pharmacy’s staff.

“The two medications were not look alike sound alike medicines and are used for completely separate treatments,” the committee said.

It concluded she breached three standards covering pharmacy professionals delivering person-centred care and considering the impact of their practice, using their professional judgement to deliver safe and effective care and demonstrating leadership, including assessing the risks in the care they provide and doing everything they can to keep those risks as low as possible.

The committed warned Ms Fola “to ensure all clinical and accuracy checks are completed to a high standard to ensure patient safety and public confidence are assured”. It also warned her “to ensure that should a patient safety issue come about in the future, such matters are acted upon without delay”.

“Any repetition of the same or similar failings is likely to result in more serious regulatory intervention,” the GPhC said. Ms Fola’s warning will be published on the register for 12 months.