The Deputy Health and Disability Commissioner has criticised a pharmacist for mixing up a prescription, resulting in a man being rushed to hospital.
The 65-year-old, who has cardiac problems and a pacemaker, was given the wrong dosage of the blood thinner warfarin.
The man was prescribed one milligram tablets coloured brown, but the pharmacist gave him bright pink 5mg tablets instead.
Six weeks later, the man was taken to hospital with severe stomach pain, blood in his urine and coughing up blood.
Commissioner Rose Wall said the pharmacist failed to comply with professional standards in processing a prescription and recommended that they get further training before returning to work.