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flag A New Zealand woman was hospitalized due to a pharmacy error swapping sertraline for cyproterone, causing serotonin syndrome.

flag A 20-something woman in New Zealand was hospitalized after a pharmacy dispensed sertraline instead of cyproterone, leading to serotonin syndrome due to a mix-up between similar-sounding brand names. flag She experienced severe symptoms including fainting, rapid heart rate, and blood pressure fluctuations, requiring emergency care and follow-ups. flag The Health & Disability Commissioner ruled the error a significant safety breach, criticizing both the technician for misreading labels and the pharmacist for failing to catch the mistake. flag The pharmacy admitted fault, apologized, and implemented changes including using generic names, adding warning signs, and training staff. flag The commissioner recommended a random audit of 20 prescriptions to ensure compliance with safety standards.

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