After two and a-half years of stress and trauma, Mikayla Wilson finally has some closure.

A prescription botch up in April 2021 lead to the Alexandra woman having to delay pregnancy for three years because of the significant risk of birth deformities.

On Monday, the Health and Disability Commission released its findings of the incident, stating the pharmacist involved breached the Code of Health and Disability Services Consumers’ Rights for failing in their obligation to check the correct medication was dispensed to a consumer.

Processes at Lake Dunstan Pharmacy in Cromwell, which has since been sold, also came under fire for its dispensing and checking standard operating procedures being in accordance with the Pharmacy Council’s standards.

Miss Wilson was prescribed isotretinoin as a treatment for acne.

However, she was incorrectly issued acitretin, a psoriasis drug not meant for women of childbearing age because of the complications it could pose.

The mistake was not discovered until three weeks later when she returned for a script repeat.

The dispensing pharmacist apologised and advised her to continue with the correct medication.

Two months later while visiting her doctor for a wrist injury, Miss Wilson learned her doctor had not been notified of the mistake.

Following his inquiries she was informed what the incorrect medication was, and the adverse side affects.

The pharmacist filed an incident notification form to the Pharmacy Defence Association 67 days after the mistake was discovered — two days after Miss Wilson’s visit to her doctor.

Deputy health and disability commissioner Rose Wall was critical the pharmacist did not provide Miss Wilson with a clear explanation about the adverse side effects of taking the incorrect medication after the dispensing error was discovered.

‘‘In my view, a reasonable pharmacist should conduct a thorough and comprehensive review about an incorrectly dispensed medication and inform the affected patient immediately about potential adverse side effects.’’

The pharmacist accepted full responsibility for the error, telling the commission she had processed the correct medication through the computer software correctly, but had ‘‘inadvertently dispensed acitretin 10mg in error’’ and did not identify the error in her final check.

She stated the isotretinoin may have been stored in the wrong place at the time, and potentially had been moved by another staff member in error.

The pharmacy stored its medications alphabetically so the two drugs should have not been stored together; however, she and another pharmacist recalled seeing the isotretinoin in the wrong location next to the acitretin.

She also explained the dispensary was busy at the time the error occurred — there were increased interruptions and only two rostered staff members working at any one time.

The commission recommended the pharmacist issue a formal apology to Miss Wilson and reflect on what she learnt from the incident.

It was recommended the pharmacy undertake an audit of its existing standard operating procedures.

The Pharmacy Council, which undertook a practise visit to the pharmacy, noted the pharmacist had taken full responsibility for the incident and shown ‘‘genuine remorse and empathy’’.

‘‘It is the council’s preliminary view that this incident is a result of work, personal and systems pressures rather than incompetence,’’ it stated.

Miss Wilson said the stress and trauma that followed as a result of the blunder left her and fiance Ben Jonutz feeling their choices had been taken away.

Nearly three years on it was still emotional for the pair and they faced uncertainty about the safety of getting pregnant.

She was concerned about the pharmacist’s competence after the mix up, especially given the lack of follow up about the error and the adverse side effects.

It was ‘‘baffling’’ the council had not wanted to review the pharmacists competency.

The recommendation the pharmacist issue a formal apology also bought up a lot of emotion.

‘‘[The pharmacist] said they didn’t know I wanted an apology,’’ Miss Wilson said.

‘‘Why should you need to have a request for an apology?

‘‘That’s not a sincere apology — yes you tick the box — but that [mistake] that had caused so much stress and trauma and anxiety, [an apology] shouldn’t need to be requested.’’

The report’s release bought some closure but was not the end of the ordeal, Miss Wilson said.

The couple were awaiting the decision of a rehearing for an ACC treatment injury claim last week, seeking assurance if there were issues with a pregnancy or the baby, medical support would be available.

There are no tests available to ensure there was no traces of acitretin in her body after the three years passed.