Date of incident: 11/02/2013

Error type: dispensing error

Patient age: 43

Patient sex: male

Brief summary of incident: The wrong directions were put on the label of methotrexate - the directions on the label should have been weekly (as per the prescription), but the label read "Take ONE daily".

Name of medication: Methotrexate;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
Methotrexate is highly toxic at the dosage frequency given and hence is likely to cause serious injury or death.

Possible cause/contributory factors: The other item I was dispensing was a "Take ONE daily" dose; I got mixed up between the two items and under time-pressure for dispensing, made the error.

Reasons why incident occurred and actions required to prevent reoccurence:
I failed to follow my SOP for dispensing an NHS prescription from a GP and also failed to make the checks outlined in my personal checking framework. I should have checked the label matched the prescription directions, as I had already made my clinical checks on the prescription - I will ensure this happens in the future. I will also develop an SOP for dispensing methotrexate as it is a medicine associated with a high level of potential risk to the patient.

Best description of this error/near miss:
wrong frequency
wrong medicine label

Date of incident: 11/02/2013

Error type: near miss

Patient age: 23

Patient sex: female

Brief summary of incident: I was in the middle of dispensing an item when I realised there was no patient information leaflet in the packaging

Name of medication: Ventolin Evohaler;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
The patient had been using the inhaler safely for a long time and was very familiar with it. Hence, it is unlikely that any harm would have come as a result of no PIL being given with the inhaler.

Possible cause/contributory factors: I had taken the PIL out to review the medicine and had forgotten to place it back in the packaging

Reasons why incident occurred and actions required to prevent reoccurence:
I will modify my personal checking framework to ensure that a check for a PIL is incorporate before the item is brought to the counter for dispensing.

Best description of this error/near miss:
PIL wrong or omitted

Date of incident: 06/02/2013

Error type: dispensing error

Patient age: 65

Patient sex: female

Brief summary of incident: Medication supplied in an unlabelled box

Name of medication: Digoxin 125mcg Tab;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
As the box was unlabelled, the patient might be taking the wrong amount of tablet which can lead to underdose or overdose. The patient might not get the therapeutic effect and on the other hand, he might get high digoxin toxicity which can he harmful to him.

Possible cause/contributory factors: Poor time management and rushed in to the products in time.

Reasons why incident occurred and actions required to prevent reoccurence:
Should have made the final check before handing in the product to the patient as well as follow SOP framework.

Best description of this error/near miss:
wrong medicine label

Date of incident: 06/02/2013

Error type: near miss

Patient age: 71

Patient sex: male

Brief summary of incident: Misread on the prescription S/L as S/R for GTN tablets and got the strength ammended to an incorrect value.

Name of medication: Glyceryl trinitrate;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
If the form that I had the prescription ammended to had been dispensed, ie the modified release buccal form instead of the sublingual form, the patient would have been taking two modified release nitrates. This would have been an overdose of nitrates and could have a fatal outcome.

Possible cause/contributory factors: Not taking enough care when reading the prescription.

Reasons why incident occurred and actions required to prevent reoccurence:
Double check the prescription before contacting the prescriber.

Best description of this error/near miss:
wrong medication

Date of incident: 29/01/2013

Error type: dispensing error

Patient age: 4

Patient sex: male

Brief summary of incident: spacer with infant mask prescribed and dispensed when the patient is a child

Name of medication: Aerochamber plus with infant mask; Miconazole

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
The patient would have been left without a spacer device to use with their inhaler. The worst case scenario would have been death due to the chance that the patient may have missed doses of their corticosteroid inhaler leading to an acute exacerbation of asthma.

Possible cause/contributory factors: Too focused on other item prescribed. I was too presumptuous that spacer device may still be suitable.

Reasons why incident occurred and actions required to prevent reoccurence:
Question anything that I feel could be an issue in the future when dispensing.

Best description of this error/near miss:
wrong product

Date of incident: 13/02/2013

Error type: dispensing error

Patient age: 67

Patient sex: female

Brief summary of incident: Forgot to tell patient to hold simvastain while on and for two days after being on clarithromycin.

Name of medication: simvastatin; clarithromycin;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
can cause severe myalgia, myopathy of muscles although not as severe as death

Possible cause/contributory factors: Not reading stockley properly

Reasons why incident occurred and actions required to prevent reoccurence:
Fully reading the stockley

Best description of this error/near miss:
verbal direction to patient wrong or omitted
interaction dispensed

Date of incident: 13/2/2013

Error type: dispensing error

Patient age: 67

Patient sex: male

Brief summary of incident: Directions on prescription were " ii tid" This was misread was Take ONE THREE times DAILY when it should of been Take TWO THEE times DAILY

Name of medication: Praxilene 100mg Capsules ;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
Due to the error, the wrong directions were put on the label and the wrong quantity of capsules were supplied to the patient which would of provided a sub-therapeutic activity of the drug.

Possible cause/contributory factors: I was rushing and simply scanned the directions assuming it was " i tid"

Reasons why incident occurred and actions required to prevent reoccurence:
When unsure about what directions mean it is best to talk to the prescriber to clarify the situation.

Best description of this error/near miss:
wrong frequency

Date of incident: 29/01/2013

Error type: dispensing error

Patient age: adult

Patient sex: male

Brief summary of incident: strip of ten tablets fell out of box onto floor at beginning of counselling, therefore patient only got some of there medication

Name of medication: desloratadine;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
although no harm would come to the patient, it may pose problems if patient where to try to get another months supply as they would be coming to the doctors too early, additionally if this error had have occured in next weeks class, the patient may have recieved the incorrect length of treatment leading to ineffective treatment and possibly encouraging antimicrobial resistance.

Possible cause/contributory factors: carelessness and trying to get through the counselling process whilst remembering all the points to go through, should have used skillet as box was very loose

Reasons why incident occurred and actions required to prevent reoccurence:
checking the packaging is appropriate and secure, if not use skillet instead ensure correct number of tablets in boxes prior to counselling.

Best description of this error/near miss:
wrong quantity

Date of incident: 29/01/2013

Error type: dispensing error

Patient age: 63

Patient sex: male

Brief summary of incident: Wrong form of inhaler dispensed, prescription stated Qvar autohaler but I dispensed Qvar aerosol. Furthermore the prescription stated 1 puff 3-4 times daily, this is the wrong dose for a steroid inhaler and thus should have been brought to the attention of the prescriber

Name of medication: Qvar 100mcg Autohaler;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
There is a likelihood that the patient cannot use a pMDI inhaler effectively and thus had been prescribed an autohaler for this reason and thus his asthma would not sufficiently be controlled. Furthermore this is an overdose, however still not a high dose of inhaled corticosteroid could still potentially have adverse effects and further predispose the patient to oral candidaisis.

Possible cause/contributory factors: Under pressure I did not perform the clinical check of the prescription properly.

Reasons why incident occurred and actions required to prevent reoccurence:
Taking more time, care and having a better checking framework is needed to overcome such errors

Best description of this error/near miss:
wrong medication
wrong frequency
verbal direction to patient wrong or omitted
wrong product

Date of incident: 12/02/2013

Error type: dispensing error

Patient age: 43

Patient sex: female

Brief summary of incident: Cyklokapron 500mg tablets presribed. Prescription directions stated "Take two tablets three times daily for four days (for menorrhagia - start when bleeding starts). I forgot to write "for four days" on label. Patient was counselled to start Cyklokapron on day 1 but not about 4 days duration.

Name of medication: Cyklokapron 500mg tablets;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
An overdose of cyklokapron can cause stomach upset and potential rash however this would be short term and not life-threatening to the patient.

Possible cause/contributory factors: Ran out of time because other product, co-codamol label took a long time to type out (many warning labels). Did not check over Cyklokapron label properly.

Reasons why incident occurred and actions required to prevent reoccurence:
Need to manage time better in future so not rushed. More thorough checking of label once printed; compare carefully to original prescription

Best description of this error/near miss:
verbal direction to patient wrong or omitted
wrong medicine label

Date of incident: 12/02/2013

Error type: dispensing error

Patient age: 58

Patient sex: female

Brief summary of incident: Stated the wrong strengh on the label for Nu-seals as 100mg instead of 75mg. Stated incorrect quantities for both Nu-seals and Praxilene. Instead of writing the number of tables/capsules in the top left corner, I stated quantity as 1 (as in one box)

Name of medication: Nu-seals 75mg tablets; Praxilene 100mg capsul

Level of harm that could have occurred: 2

The reason you think the potential harm is at the level you have chosen:
The correct strength was dispensed and given to the patient who was counselled on taking one tablet and the label states clearly take ONE tablet in the MORNING.

Possible cause/contributory factors: Praxilene capsules were 100mg so I must have looked at the wrong one.

Reasons why incident occurred and actions required to prevent reoccurence:
Check labels more accurately and compare against the prescription. I now know to state the actual number of tablets given out in the top left corner.

Best description of this error/near miss:
wrong dose strength

Date of incident: 05/02/2013

Error type: dispensing error

Patient age: 62

Patient sex: female

Brief summary of incident: WRONG FORM OF RAMIPRIL DISPENSED. ALTHOUGH THIS WILL NOT BE CLINICALLY HARMFUL MORE CARE SHOULD BE TAKEN BECAUSE -20 MARKS

Name of medication: RAMIPRIL TABS; RAMIPRIL CAPS;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
CORRECT STRENGTH, JUST WRONG FORM

Possible cause/contributory factors: USED TO SEEING CAPSULES COMPARED TO TABS DISPENSED

Reasons why incident occurred and actions required to prevent reoccurence:
CARE WHEN DISPENSING, AND EXTRA CARE WITH FINAL CHECK

Best description of this error/near miss:
wrong medication

Date of incident: 13/02/2013

Error type: dispensing error

Patient age: 50

Patient sex: female

Brief summary of incident: Warning labels missing for erythromycin tablets and inappropriate counselling or advise for simvastatin

Name of medication: Erythromycin 250mg tablets; Simvastatin 10mg

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
Two missing BNF warnings which are labels 5 and 25 for erythromycin tablets. Missing warning labels could lead to wrong way of taking this medicine.As simvastatin and erythromycin should not be taken together, I told the patient to stop simvastatin during 7 days of antibiotic and for a further 7 days which is wrong and it is too long for the patient to stop taking simvastatin.

Possible cause/contributory factors: Mistook wrong product for erythromycin in BNF and hence lead to wrong warning labels.

Reasons why incident occurred and actions required to prevent reoccurence:
Need to check the label carefully and check for the interactions in Stockley.

Best description of this error/near miss:
verbal direction to patient wrong or omitted
wrong medicine label

Date of incident: 20/02/2013

Error type: dispensing error

Patient age: 71

Patient sex: female

Brief summary of incident: Only gave one roll of absorbent cotton instead of two.

Name of medication: absorbent cotton;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
Not serious.

Possible cause/contributory factors: Rushing and overlooking the quantity

Reasons why incident occurred and actions required to prevent reoccurence:
read everything slowly and clearly

Best description of this error/near miss:
wrong quantity

Date of incident: 06/02/2013

Error type: dispensing error

Patient age: 66

Patient sex: female

Brief summary of incident: Dispensed Losartan Potassium as a twice daily dose instead of a once daily

Name of medication: Losartan Potassium;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
Overdose

Possible cause/contributory factors: Reading the dosing in the bnf too quickly

Reasons why incident occurred and actions required to prevent reoccurence:
If im under pressure, stop and start again without rushing

Best description of this error/near miss:
wrong dose strength

Date of incident: 27/02/2013

Error type: dispensing error

Patient age: 35

Patient sex: female

Brief summary of incident: Wrong quantity of flucloxacillin capsules dispensed. 14 dispensed when should have been 28. "Take one tablet" written as directions when form of medicine was capsules.

Name of medication: Flucloxacillin 250mg;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
An overdose was not dispensed, however this underdose could still cause serious harm to the patient as they would not have sufficient treatment for their infection which could lead to the infection worsening and also, as the patient was not given a full course of the antibiotic, she has been put at risk of developing antibiotic resistance.

Possible cause/contributory factors: Poor checking accuracy under pressure.

Reasons why incident occurred and actions required to prevent reoccurence:
Create a more clear checking framework to allow me to check things accuracy, even when under pressure.

Best description of this error/near miss:
wrong quantity

Date of incident: 04/03/2013

Error type: dispensing error

Patient age: 62

Patient sex: male

Brief summary of incident: Wrong dosing interval stated on label - not those stated by the doctor.

Name of medication: Temgesic 60mcg tablets;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
The dosing interval was stated on label as four to six hours rather than six to eight hours. This could have resulted in overdose or toxicity due to increased levels of the drug in the body.

Possible cause/contributory factors: Time constraints and rushing

Reasons why incident occurred and actions required to prevent reoccurence:
I will ensure that I always check my labels against prescriptions before handing out to a patient.

Best description of this error/near miss:
wrong frequency

Date of incident: 26/02/2013

Error type: dispensing error

Patient age: 32

Patient sex: male

Brief summary of incident: Wrong dose on Rx, clinical check not completed. 10ml prn on Rx, should be 5ml 3-4 times daily

Name of medication: simple linctus;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
The BNF states "preparations such as simple linctus have the advantage of being harmless" although care still has to be taken with all medicines.

Possible cause/contributory factors: My own carelessness.

Reasons why incident occurred and actions required to prevent reoccurence:
Read all of the BNF entry to ensure clinical appropriateness of the Rx. Do a final clinical check, while waiting to counsel patient.

Best description of this error/near miss:
wrong dose strength
wrong frequency

Date of incident: 01/03/2013

Error type: dispensing error

Patient age: 33

Patient sex: male

Brief summary of incident: Major labeling error, incorrect warning labels for the formulation dispensed

Name of medication: sporanox;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
As incorrect warning labels are present/omitted. No major harm should come about due to this. But there is potential for harm due to omitted warnings.

Possible cause/contributory factors: Stress/time constraints leading to increased pressure, which lead to misreading of the BNF, and therefore the incorrect information was passed onto the patient.

Reasons why incident occurred and actions required to prevent reoccurence:
Always recheck the label before dispensing, use the appendix for the products warning labels opposed to the monograph, to avoid confusion between formulations.

Best description of this error/near miss:
wrong medicine label

Date of incident: 04/03/2013

Error type: dispensing error

Patient age: 49

Patient sex: male

Brief summary of incident: Prescription was for Zomorph 10mg capsules (m/r morphine sulfate), one four times daily. Failed to identify that Zomorph was a m/r product which would be taken every 12 hours, rather than immediate release (taken every 4 hours).

Name of medication: Zomorph 10mg Capsules;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
If the patient followed the instructions from product label and counselling, the patient would have overdosed on morphine, which is likely to be fatal to the patient.

Possible cause/contributory factors: Not taking sufficient care when reading BNF and PIL.

Reasons why incident occurred and actions required to prevent reoccurence:
I will be extremely careful checking doses and frequency of medication in the future. I will not feel pressured to rush my clinical checks, as doing so may endanger my patient.

Best description of this error/near miss:
wrong frequency

Date of incident: 6/3/2013

Error type: dispensing error

Patient age: N/A

Patient sex: female

Brief summary of incident: oxynorm 5mg/5ml was dispenced from a pcd1 in which the quantity to be dispenced was not written in both words and figures

Name of medication: oxynorm liquid 5mg/5ml;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
Although a legal issu the wrong quantity could have been dispenced leadign to an overdose for the patient or the patient continuing to take the medication for longer than the prescriber intended

Possible cause/contributory factors: Confusion around whether this was a requirement for private scripts

Reasons why incident occurred and actions required to prevent reoccurence:
encorporating this into my checking frame work

Best description of this error/near miss:
Legal issue

Date of incident: 27/2/2013

Error type: dispensing error

Patient age: 9

Patient sex: female

Brief summary of incident: wrong strength included on the label, 50mg/ml instead of 50mg/5ml

Name of medication: trimethoprim 50mg/5ml;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
The dosing instruction were still correct for the patient

Possible cause/contributory factors: time pressure

Reasons why incident occurred and actions required to prevent reoccurence:
double checking of the strength included on the label

Best description of this error/near miss:
wrong dose strength

Date of incident: 4/3/2013

Error type: dispensing error

Patient age: 45

Patient sex: male

Brief summary of incident: Dispensed 100 Cyclizine instead of 21.

Name of medication: Cyclizine;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
There have been reports of abuse of cyclizine, either oral or intravenous, for its euphoric or hallucinatory effects. The concomitant misuse of Cyclizine Hydrochloride Tablets with large amounts of alcohol is particularly dangerous, since the antiemetic effect of cyclizine may increase the toxicity of alcohol. Patient could also potentially sell the medicine to others who abuse it.

Possible cause/contributory factors: I printed the label first and when I received the only box of cyclizine back from the marker after they were finished I applied the label immediately without checking quantity.

Reasons why incident occurred and actions required to prevent reoccurence:
Double checking quantities.

Best description of this error/near miss:
wrong quantity

Date of incident: 27/02/2013

Error type: dispensing error

Patient age: N/A

Patient sex: male

Brief summary of incident: Inappropriate item supplied to chiropodist

Name of medication: 5ml Amorolfine hydrochloride nail lacquer; 15

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
I got a written request for stock to be wholesale dealing to a chiropodist. Chiropodists are only allowed POMs which are available on MHRA website. The exempted list for chiropodists does not include hydrocortisone 2.5% cream. They are only allowed hydrocortisone cream 1%. Therefore, it is an inappropriate supply.

Possible cause/contributory factors: Forgot to check on the list in MHRA.

Reasons why incident occurred and actions required to prevent reoccurence:
Always check in MHRA when get written request from chiropodists, midwives and optometrists.

Best description of this error/near miss:
wrong product

Date of incident: 06/03/2013

Error type: near miss

Patient age: N/A

Patient sex: male

Brief summary of incident: hs/nocte interchanged between prescription and label

Name of medication: 28 Mirtazapine 30mg orodispersible tablets;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
Could cause harm to the patient as therapeutic effect could be changed.

Possible cause/contributory factors: Did not do final checking on the label before printing it out.

Reasons why incident occurred and actions required to prevent reoccurence:
Always double check the label before and after printed them off.

Best description of this error/near miss:
wrong frequency
wrong medicine label

Date of incident: 04/03/2013

Error type: dispensing error

Patient age: 23

Patient sex: female

Brief summary of incident: The patient was prescribed 56 promethazine hydrochloride 25mg tablets. Although the correct quantity was givin out and the correct direction, the wrong patient name was included on the label.

Name of medication: Promethazine Hydrochloride;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
The patienet was given the correct medication and was aware of why they were prescribed it, and councelled on how to take it. As a result it would not have caused any harm. However, if the medication had have been given out to the patient whose name was on the label(the wrong patient) and myself or the patient failed to spot the error this could have led to more serious consequences.

Possible cause/contributory factors: I faied to check the accuracy of my label before dispensing the medication to the patient.

Reasons why incident occurred and actions required to prevent reoccurence:
I will ensure to check that I have put the correct patient name on the label.

Best description of this error/near miss:
wrong medicine label

Date of incident: 12/03/2013

Error type: dispensing error

Patient age: 51

Patient sex: male

Brief summary of incident: Private prescription for control drugs (PCD1) coded like it was an NHS prescription. Cost not marked on the prescription.

Name of medication: Temazepam;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
It is a dispensing error which may cause confusion if the prescription was sent to the BSO at the end of the month. It does not cause potential harm to the patient however.

Possible cause/contributory factors: Lack of understanding of prescription endorsement requirements.

Reasons why incident occurred and actions required to prevent reoccurence:
Study guidances such as manual, General Legal Requirement and etc.

Best description of this error/near miss:
Prescription coded incorrectly

Date of incident: 12/03/2013

Error type: dispensing error

Patient age: 54

Patient sex: female

Brief summary of incident: Figures used instead of words within directions on lable. Wrong legal category recorded (POM instead of CD Inv POM recorded). Warning label 3 instead of warning label 2 on product. Wrong coding. Fate of document not recorded.

Name of medication: Dihydrocodeine;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
Directions written in figures rather than words can cause confusion to patient while taking medicine. Warning label 3 instead of warning label 2 can have potential harm to patient if the patient drink alcohol during the treatment. Other dispensing errors are less likely to cause potential harm to the patient, but they may cause confusion if prescription was sent to BSO.

Possible cause/contributory factors: Carelessness and lack of understanding of appropriate labelling.

Reasons why incident occurred and actions required to prevent reoccurence:
Revise NPSA guidance on QOL and check prescription and label more systematically.

Best description of this error/near miss:
wrong frequency
Labelling errors

Date of incident: 06/03/2013

Error type: dispensing error

Patient age: 32

Patient sex: male

Brief summary of incident: The prescription was for a schedule 3 controlled drug and the prescription did not comply with the legal requirements

Name of medication: Buprenorphine ;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
The issues were legal

Possible cause/contributory factors: Got mixed up with legal requirements between CD 2 and CD 3

Reasons why incident occurred and actions required to prevent reoccurence:
Modification if checklists

Best description of this error/near miss:
Dispensed a prescription that was not legally valid

Date of incident: 06/03/2013

Error type: near miss

Patient age: 9

Patient sex: female

Brief summary of incident: Equasym XL 10mg capsules were to be prescribed once daily. The prescription stated BD. I failed to realise that this had to be amended by the prescriber and the medicine was dispensed, labelled and councelled to be taken BD.

Name of medication: Equasym XL 10mg Capsules;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
Equasym is a schedule 2 controlled drug, and a double dose has been handed out to a child.

Possible cause/contributory factors: I did not recognise that XL formulations are designed for once daily administration.

Reasons why incident occurred and actions required to prevent reoccurence:
Take more care when checking doses in the BNF, and making a personal note that XL formulations are to be administered once daily.

Best description of this error/near miss:
wrong frequency

Date of incident: 06/03/2013

Error type: near miss

Patient age: 32

Patient sex: female

Brief summary of incident: Initially told the wrong dosage advice to prescriber for zormorph due to confusion between regular products which are given 3-4 times daily and m/r products which are given every 12 hours

Name of medication: Zormorph 10 mg;

Level of harm that could have occurred: 2

The reason you think the potential harm is at the level you have chosen:
Although it was a higher dose than intended by prescriber, patients can be prescribed very high doses of opioids in appropriate circumstances

Possible cause/contributory factors: Misunderstanding of the following statement: "Dose every 12 hours, dose adjusted according to daily morphine requirement" to mean that the dose is adjusted every 12 hours rather than it is given every 12 hours

Reasons why incident occurred and actions required to prevent reoccurence:
More careful reading of subheadings in the BNF before approaching prescriber

Best description of this error/near miss:
wrong frequency

Date of incident: 27/03/2013

Error type: dispensing error

Patient age: 32

Patient sex: male

Brief summary of incident: Directions on the label for the product was written was as " Take THREE or FOUR spoonfuls DAILY" instead of " Take ONE 5ml spoonful THREE or FOUR times s day"

Name of medication: Simple Linctus (200ml);

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
The size of the spoonful is not indicated for and the patient may be tempted to use other sized spoons to administer the medicine.

Possible cause/contributory factors: Not double and triple checking label before dispensing

Reasons why incident occurred and actions required to prevent reoccurence:
Check label against prescription for directions

Best description of this error/near miss:
wrong dose strength
wrong frequency

Date of incident: 4/3/2013

Error type: dispensing error

Patient age: X (not included on script)

Patient sex: female

Brief summary of incident: Incorrect name on the label dispensed

Name of medication: 30mg MST continus tablets;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
The wrong medication could have went to the wrong patient.

Possible cause/contributory factors: Rushing to complete labels. Not paying attention that there are in fact two people receiving two medications

Reasons why incident occurred and actions required to prevent reoccurence:
Carefully check labels before dispensing, calm myself not to rush

Best description of this error/near miss:
mismatch

Date of incident: 05/03/2013

Error type: dispensing error

Patient age: 48

Patient sex: male

Brief summary of incident: Wrong quantity dispensed to patient. Directions on label were not the same as those on prescription.

Name of medication: Gabapentin 300mg Capsules;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
Patient could have misinterpreted the directions on the label and taken an overdose.

Possible cause/contributory factors: Lapse in concentration

Reasons why incident occurred and actions required to prevent reoccurence:
Be more thorough when checking product and make sure to maintain full concentration during dispensing.

Best description of this error/near miss:
wrong frequency
wrong quantity

Date of incident: 08/03/2013

Error type: dispensing error

Patient age: 45

Patient sex: male

Brief summary of incident: Major label error - wrong patient name

Name of medication: anafranil sr tablets;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
The patient was already taking an opiod analgesic on prescription. Anafranil sr tablets is a tricyclic antidepressant. These can increase the CNS toxicity of opiod analgesics. Opiod analgesics can also increase the sedative effects of tricyclic antidepressants.

Possible cause/contributory factors: Lack of attention to detail

Reasons why incident occurred and actions required to prevent reoccurence:
Ensure to consult personal checking framework before a medicine is dispensed to patient, to check for labelling errors.

Best description of this error/near miss:
interaction dispensed
wrong patient name on label

Date of incident: 12/03/2013

Error type: dispensing error

Patient age: UNKNOWN

Patient sex: female

Brief summary of incident: Rx for Primolut N 5mg (norethisterone) tabs, with directions "i tid start 3 days prior to menses". So indication was to delay menses. I omitted the word "start" from the label, omitting start implies that the tab is only taken 3 days before menses, whereas it should be taken 3 days before and continued, until the menses can resume. Menses will occur 2 to 3 days after the tab is stopped.

Name of medication: Primolut N 5mg (norethisterone) tabs;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
There was no life threatening issues with only having a few days cover of menses prevention.

Possible cause/contributory factors: Oversight

Reasons why incident occurred and actions required to prevent reoccurence:
Check the label before printing that exactly what is on the Rx is on the label.

Best description of this error/near miss:
omitted dose

Date of incident: 20/03/2013

Error type: near miss

Patient age: 67

Patient sex: male

Brief summary of incident: Patient instructed to use two spoonfuls of gel rather than the prescribed one spoonful.

Name of medication: Miconazole 20 mg/g oromucosal gel;

Level of harm that could have occurred: 2

The reason you think the potential harm is at the level you have chosen:
Miconazole overdose may cause vomiting or diarrhoea

Possible cause/contributory factors: Error checking the size of spoon

Reasons why incident occurred and actions required to prevent reoccurence:
Thorough checking of administration instructions

Best description of this error/near miss:
wrong dose strength
verbal direction to patient wrong or omitted

Date of incident: 20/03/2013

Error type: dispensing error

Patient age: None

Patient sex: female

Brief summary of incident: Assumption made within directions on label although SPC standard dose stated. Date from prescription not included in POR entry.

Name of medication: Tears Naturale eye drops;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
It is an technical error on labelling, which will not not cause significant harm to patient as long as patient is counselled appropriately.

Possible cause/contributory factors: No clear direction on prescription.

Reasons why incident occurred and actions required to prevent reoccurence:
Confirm the dose with prescriber

Best description of this error/near miss:
Assumption ithi directions on label

Date of incident: 20/03/2013

Error type: near miss

Patient age: 7

Patient sex: female

Brief summary of incident: Form of a Schedule 2 CD not on prescription, making the prescription legally invalid, although only one form available in BNF

Name of medication: Concerta XL;

Level of harm that could have occurred: 2

The reason you think the potential harm is at the level you have chosen:
A product with different form might be dispensed to patient. This is unlikely in this case as there is only one form available in BNF.

Possible cause/contributory factors: Carelessness

Reasons why incident occurred and actions required to prevent reoccurence:
Follow SOP in dispensing

Best description of this error/near miss:
wrong medication

Date of incident: 13/03/2013

Error type: near miss

Patient age: 30

Patient sex: female

Brief summary of incident: Rx was out of date. Consult the GP outside of 45mins time allocation.

Name of medication: Diazepam tablets 5mg; cefalexin 250mg caps;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
it was a typing error and might have no harm to the patient at all

Possible cause/contributory factors: misread the Rx without checking it thoroughly

Reasons why incident occurred and actions required to prevent reoccurence:
carefully check the Rx

Best description of this error/near miss:
Rx is out of date

Date of incident: 04/03/2013

Error type: dispensing error

Patient age: 56

Patient sex: male

Brief summary of incident: 28 sonata caps was requested by the Rxber. however, due to not reading the BNF carefully, i missed the part where it says it can only be used one daily for up to 14 days only. due to this error, i dispensed 14 caps and make an owing for another 14caps to the patient.

Name of medication: sonata caps;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
patient might get an overdose if the patient was dispensed with 28 caps

Possible cause/contributory factors: not reading the BNF carefully

Reasons why incident occurred and actions required to prevent reoccurence:
read the BNF carefully

Best description of this error/near miss:
verbal direction to patient wrong or omitted
wrong quantity

Date of incident: 06/03/2013

Error type: dispensing error

Patient age: 29

Patient sex: female

Brief summary of incident: Read the BNF wrong, didnt realise that the product was a modified release product and changed the dosing frequency of the controlled released form to that of an immediate release causing an overdose.

Name of medication: MST Continus;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
The patient would have received an overdose and probably suffered respiratory depression.

Possible cause/contributory factors: Rushing

Reasons why incident occurred and actions required to prevent reoccurence:
Dedicate more time to thoroughly checking the BNF and looking out for once a day and other controlled release preparations.

Best description of this error/near miss:
wrong dose strength
wrong frequency

Date of incident: 19/04/2013

Error type: dispensing error

Patient age: 7

Patient sex: male

Brief summary of incident: Equasym XL product prescribed twice daily, should only be once daily

Name of medication: Equasym XL 10mg;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
This would be an incorrect dosing for this medication and as the patient had the medication before this would lead to the medicine being used ineffectively

Possible cause/contributory factors: Improper understanding of XL preparations, I believed that XL was 12 hour release I have since corrected this error

Reasons why incident occurred and actions required to prevent reoccurence:
More care when reading the BNF and making sure my checking framework is more robust

Best description of this error/near miss:
wrong frequency

Date of incident: 3/2/2014

Error type: near miss

Patient age: 55

Patient sex: female

Brief summary of incident: Wrong advice given in counselling on doasge. Labelling issues

Name of medication: Salamol 5mg Steri-neb; Deltacortril e/c 5mg t

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
The dosage told for Deltacortril e/c 5mg tabs during counselling was an under-dose even though the label had the correct dosage.

Possible cause/contributory factors: Rushing towards the end to make sure that I had covered everything.

Reasons why incident occurred and actions required to prevent reoccurence:
Better time management and review everything before counselling.

Best description of this error/near miss:
wrong dose strength
wrong frequency
verbal direction to patient wrong or omitted

Date of incident: 03/02/2014

Error type: dispensing error

Patient age: 6

Patient sex: female

Brief summary of incident: Ventolin inhale was labelled up as inhale one puff twice daily when required instead of inhale one puff when required

Name of medication: 1;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
as the patient may have taken two many puffs and lead to an overdose and therefore side effects would be seen as palpitations, tremor and headache

Possible cause/contributory factors: when labelling i got mixed up between the other inhaler (flixotide) directions

Reasons why incident occurred and actions required to prevent reoccurence:
always double check that the directions on the script are the same as the directions on the label

Best description of this error/near miss:
wrong dose strength
wrong frequency

Date of incident: 10/03/2014

Error type: dispensing error

Patient age: 4

Patient sex: male

Brief summary of incident: I dispensed Phenoxymethylpenicillin which the dose for a child was too high.

Name of medication: Phenoxymethyl penicillin;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
It was an overdose but not by too much that i would think could kill the patient

Possible cause/contributory factors: Looked in the Bnf insteadt of the BNF-c

Reasons why incident occurred and actions required to prevent reoccurence:
Double check the patients age

Best description of this error/near miss:
wrong dose strength

Date of incident: 16/2/2015

Error type: dispensing error

Patient age: 54

Patient sex: male

Brief summary of incident: dispensed wrong strength of plendil (10mg instead of what should have been 5mg tablets)

Name of medication: Plendil;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
because the wrong strength was dispensed this could have resulted in a potential over dose

Possible cause/contributory factors: not doing a second accuracy check and not being thorough enough

Reasons why incident occurred and actions required to prevent reoccurence:
i have already made a checklist for clinical and accuracy checking and the labelling process so that no steps are missed in the dispensing process

Best description of this error/near miss:
wrong dose strength

Date of incident: 23/02/2015

Error type: dispensing error

Patient age: 32

Patient sex: female

Brief summary of incident: Flagyl 400mg was dispensed instead of the requested 200mg

Name of medication: Flagyl;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
An overdose was prescribed and this could have caused serious harm to the patients health

Possible cause/contributory factors: Not taking time to read the product carefully

Reasons why incident occurred and actions required to prevent reoccurence:
Double checking that the product being dispensed is of the correct strength where multiple strengths are available

Best description of this error/near miss:
wrong dose strength

Date of incident: 23/02/15

Error type: dispensing error

Patient age: 7

Patient sex: male

Brief summary of incident: Two liquid based products on script. mixed up the dosing instructions for each when labelling.

Name of medication: galenphol paed linctus; phenergan elixir;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
the incorrect dose for phenergan would have resulted in a serious overdose in practice.

Possible cause/contributory factors: unfortunatley was in a rush as had to make up the galenphol form a larger stock bottle. Did not know where to find this and was unsure of the protocols required e.g. measuring out required volume and getting volume checked before proceeding. Wasted time, which resulted in me rushing through labels.

Reasons why incident occurred and actions required to prevent reoccurence:
SOPs in particular for labelling and final checks have been revised.

Best description of this error/near miss:
wrong dose strength
wrong frequency

Date of incident: 10/02/2016

Error type: dispensing error

Patient age: 70

Patient sex: female

Brief summary of incident: Advice offered was to stop simvastatin 40mg tablets for the duration of antibiotic treatment + 7 days after last dose. This advice was incorrect, as it is only necessary to stop simvastatin for the duration of the antibiotic.

Name of medication: Simvastatin;

Level of harm that could have occurred: 2

The reason you think the potential harm is at the level you have chosen:
It is not a life-threatening error, but it involves unnecessary stopping of medication.

Possible cause/contributory factors: Misunderstanding of BNF directions

Reasons why incident occurred and actions required to prevent reoccurence:
Read the BNF more carefully

Best description of this error/near miss:
verbal direction to patient wrong or omitted

Date of incident: 22/02/2016

Error type: dispensing error

Patient age: 39

Patient sex: male

Brief summary of incident: The precription was for "Gary" but I labelled it "Gerry"

Name of medication: Arythmol 300mg tablets; Aspirin e/c 75 mg tab

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
I could have been handing medication to a person it was not intended for

Possible cause/contributory factors: I was distracted and rushing

Reasons why incident occurred and actions required to prevent reoccurence:
I will perform thorough checks between the prescription and dispensed medications

Best description of this error/near miss:
Wrong name on label

Date of incident: 03/02/1916

Error type: dispensing error

Patient age: 6

Patient sex: female

Brief summary of incident: Warning label 21 missing on label.

Name of medication: Ibuprofen Oral Suspension Sugar free 100mg/5ml;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
As this warning label indicates that the drug should be taken with or just after food or a meal, GI upset could occur, which would be transient and so is minor short term harm.

Possible cause/contributory factors: In my final label checklist, did not include warning labels.

Reasons why incident occurred and actions required to prevent reoccurence:
Amended the checklist and highlighted to ensure vital warning labels are not missed.

Best description of this error/near miss:
wrong medicine label

Date of incident: 13/04/1916

Error type: dispensing error

Patient age: 21

Patient sex: female

Brief summary of incident: Wrong quantity of tablets on label - quantity was in the upper left hand corner of the label and in brackets beside the drug name which indicates that double the quantity actually supplied had been supplied.

Name of medication: Femodette;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
This is a quantity labelling error which would cause the patient confusion and most likely to query it, but would not cause physical harm.

Possible cause/contributory factors: I had seen an incorrect example and thought it was the correct way to label for three cycles worth of contraception medicine.

Reasons why incident occurred and actions required to prevent reoccurence:
Reviewed mark sheet, noted that this is a confusing way to label, and added it into checklist.

Best description of this error/near miss:
wrong quantity

Date of incident: 13/04/2016

Error type: dispensing error

Patient age: 43

Patient sex: male

Brief summary of incident: Incorrect balance recorded in error log.

Name of medication: Actiq lozenges 200 microgram;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
This is a legal clerical error but will not harm the patient

Possible cause/contributory factors: Thought that there were three actiq lozenges in the stock list prior to dispensing but it was three packets of three actiq lozenges.

Reasons why incident occurred and actions required to prevent reoccurence:
I will take greater care when checking initial stock balance.

Best description of this error/near miss:
CD reg error

Date of incident: 24/02/2016

Error type: dispensing error

Patient age: 28

Patient sex: male

Brief summary of incident: In the write up sheet, there was no differentiation between the expiry date and best before. It is important to note that these mean different things and to not just check the date but what is implied by it.

Name of medication: Ventolin evohaler 100mcg/inhalation 200dose;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
If a medication is supplied which has expired or is past its use by date there is a risk of toxicity and decreased efficacy and so it is important to make note of this while performing the check on the product.

Possible cause/contributory factors: I was rushing to get the item dispensed in time but actually had excess time at the end and should have went back to double check the scripts/items.

Reasons why incident occurred and actions required to prevent reoccurence:
I will go through my check list for the item to be dispensed thoroughly each time I dispense.

Best description of this error/near miss:
record keeping error

Date of incident: 01/03/2017

Error type: dispensing error

Patient age: 45

Patient sex: female

Brief summary of incident: I obliterated content in the CD Register

Name of medication: Diamorphine Hydrochloride 10mg Solution for inject

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
The error would not have affected the patient as they still received the correct product at the right dose.

Possible cause/contributory factors: Was not aware of the protocol required if make a mistake in the CD Register

Reasons why incident occurred and actions required to prevent reoccurence:
Put a footnote on errors- do not obliterate content.

Best description of this error/near miss:
Error in CD Register

Date of incident: 17/01/2017

Error type: dispensing error

Patient age: 42

Patient sex: female

Brief summary of incident: Told patient that we did not have their medication in stock however it was in the dispensary

Name of medication: Clotrimazole 1% cream;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
A delay in the supply of medication could worsen their condition and this was unnecessary

Possible cause/contributory factors: Not checking all areas thoroughly

Reasons why incident occurred and actions required to prevent reoccurence:
Ask pharmacy technician for help when I cannot find an item and do not assume it is not in stock. Also check online stock list

Best description of this error/near miss:
medicine omitted

Date of incident: 10/01/2018

Error type: dispensing error

Patient age: 15

Patient sex: male

Brief summary of incident: In the counselling for Nystatin I forgot to mention to use it after meals and to apply it directly to the lesions in the mouth

Name of medication: Nystatin oral suspension; Daktacort;

Level of harm that could have occurred: 2

The reason you think the potential harm is at the level you have chosen:
Omitting these instructions meant that the patient could incorrectly use the product meaning their condition is not appropriately treated

Possible cause/contributory factors: rushing through the counselling and not carefully reading the PIL

Reasons why incident occurred and actions required to prevent reoccurence:
carefully read the PIL before counselling the patient in order to learn the key points

Best description of this error/near miss:
verbal direction to patient wrong or omitted

Date of incident: 09/01/2018

Error type: dispensing error

Patient age: 9

Patient sex: female

Brief summary of incident: The dose of Trimethoprim suspension SF 50mg/5ml was written as "5ml QDS". I failed to realize the mistake as it is an inappropriate dose for UTI. The correct dose was supposed to be 4mg/kg twice daily ( max per dose 200mg).

Name of medication: ;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
It is an overdose as it should have been given twice daily instead of four times a day

Possible cause/contributory factors: Nerves or just not reading the directions properly

Reasons why incident occurred and actions required to prevent reoccurence:
Ensure to read the everything fully. I will take my time to understand and try not to overthink.

Best description of this error/near miss:
wrong dose strength
wrong frequency

Date of incident: 08/01/2018

Error type: dispensing error

Patient age: 45

Patient sex: male

Brief summary of incident: Out of date Rx dispensed.

Name of medication: Cefaclor 375mg MR tablets; Aciclovir cream 5%

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
The correct products were dispensed at the correct strengths, therefore no harm would have occurred to the patient.

Possible cause/contributory factors: Not carrying out legal check of prescription accurately.

Reasons why incident occurred and actions required to prevent reoccurence:
Have a sufficient legal checklist in place for future checks of prescriptions to ensure this does not occur again.

Best description of this error/near miss:
Out of date Rx dispensed.

Date of incident: 17/01/2018

Error type: near miss

Patient age: 10 years 6 months

Patient sex: female

Brief summary of incident: Patient name was spelt wrong on the label, which could lead to dispensing to the wrong patient. Three contacts were made with the prescriber, initially missing the issue with prescribing tetracycline for someone who is a 10 year old. The wrong BSO code was given for erythromycin on the prescription. The side effects and expiry date of erythromycin was not recorded. The fate of the document was not recorded.

Name of medication: Chlorhexidine mouthwash 0.2%; Erythromycin et

Level of harm that could have occurred: 2

The reason you think the potential harm is at the level you have chosen:
The mistakes made on the were mainly a result of poor documentation on the worksheets and mistakes regarding to spelling and recording information. However, side effects for erythromycin were not stated and it took longer than expected to realise that a 10 year old cannot be given tetracycline, so a suitable alternative had to be suggested.

Possible cause/contributory factors: Not organising my time well. Feeling rushed when having to complete the worksheets led to not everything being documented and spelling mistakes. Panicking when I was in the situation where I had to suggest an alternative medication.

Reasons why incident occurred and actions required to prevent reoccurence:
Organise my time and decide how. will use it in advance. Look at the mistakes regarding spelling and worksheets and ensure that they are filled in in future. Know how to search for possible alternatives for medicines, remember to ask if they are penicillin allergic.

Best description of this error/near miss:
verbal direction to patient wrong or omitted
wrong medicine label

Date of incident: 17/01/2018

Error type: dispensing error

Patient age: N/A

Patient sex: male

Brief summary of incident: Incomplete recording of expiry dates of the products asked for in the wholesale.

Name of medication: Ventolin 2.5mg nebules; Atrovent UDVs 500mcg/

Level of harm that could have occurred: 2

The reason you think the potential harm is at the level you have chosen:
If the recording of expiry dates did not occur sufficiently, this may cause a problem for the use of the dispensed products within the GP practice.

Possible cause/contributory factors: Not completing dispensing form accurately.

Reasons why incident occurred and actions required to prevent reoccurence:
Ensure that all sections of the dispensing form are completed.

Best description of this error/near miss:
Incomplete recording of Atrovent and Ventolin expiry dates.

Date of incident: 24/01/2018

Error type: near miss

Patient age: 22

Patient sex: female

Brief summary of incident: An error was made when recording the legal category of a peak flow meter. It was recorded as a GSL product when the product does not have a legal category.

Name of medication: Pocketpeak Peak Flow Meter Std Range;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
No potential harm could be caused to the patient in recording the product as a GSL.

Possible cause/contributory factors: Not knowing how to find out the legal category of the product.

Reasons why incident occurred and actions required to prevent reoccurence:
Know in future that if the legal category is not stated, then the product does not have one.

Best description of this error/near miss:
Mistake in recording the legal category of the product

Date of incident: 16/01/2018

Error type: dispensing error

Patient age: 21

Patient sex: male

Brief summary of incident: Patient was privately prescribed Airomir and Qvar autohalers. the MDI versions of both were dispensed instead. Labels also not added to the inhalers.

Name of medication: Airomir Autohaler; QVAR Autohaler;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
Dose and frequency remained the same, just an alternate product dispense. May cause a bit of confusion to the patient.

Possible cause/contributory factors: Assumed an autohaler was an MDI Careless lifting of medications from the shelves.

Reasons why incident occurred and actions required to prevent reoccurence:
Google the image of the products so that I would have a rough idea of what to expect. Remember to label both the outside and the inhaler/autohaler itself.

Best description of this error/near miss:
wrong medication
wrong medicine label

Date of incident: 15/01/2018

Error type: dispensing error

Patient age: 6 years and 2 months

Patient sex: male

Brief summary of incident: Wrote James Wright on the label instead of the correct name (Lesley Wright). I failed to notice this when checking the product labels and as result give the patient the medications with the incorrect name.

Name of medication: Ventolin Evohaler; Flixotide Evohaler 50 micr

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
The patient may have noticed that the incorrect name was put on the labels and may not have not taken the asthma medication as a result because they may think it was not the correct medicine for them. This could of resulted in an asthma attack. Also if the prescription had been left aside for the patient to collect later, it could have been given out to another patient with the name James Wright and this could of caused harm to this patient.

Possible cause/contributory factors: Failure to concentration fully on my final check of the products and not having a comprehensive checking list for checking the label.

Reasons why incident occurred and actions required to prevent reoccurence:
I have written up a comprehensive checking list for checking the labels and a final checklist which includes a final check of the label. This should prevent the incidence occurring again.

Best description of this error/near miss:
Incorrect patient name on the label.

Date of incident: 15/01/2018

Error type: near miss

Patient age: N/A

Patient sex: 

Brief summary of incident: The wrong form of prednisolone dispensed

Name of medication: Prednisolone 5mg tablets;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
The medicines should be prednisolone 5mg tabs instead of prednisolone GR 5mg tabs

Possible cause/contributory factors: I did not pay close attention to the different forms of drugs in the dispensary

Reasons why incident occurred and actions required to prevent reoccurence:
I will be more careful when select medicines in the dispensary and be aware of the different form of medicines available.

Best description of this error/near miss:
wrong medication

Date of incident: 9/01/2018

Error type: dispensing error

Patient age: 31

Patient sex: female

Brief summary of incident: Patient is to be dispensed with Amoxicillin S/F 3g sachets. I have omitted S/F on the label of the product.

Name of medication: Amoxicillin S/F 3g sachets;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
S/F stands for sugar free and omitting it will not cause patient any harm as the dosing was correct.

Possible cause/contributory factors: Time constraint

Reasons why incident occurred and actions required to prevent reoccurence:
I will read my label again and compare it with the prescription to ensure there are no mistakes before dispensing the item to patient.

Best description of this error/near miss:
medicine omitted

Date of incident: 09/01/2018

Error type: dispensing error

Patient age: 31

Patient sex: female

Brief summary of incident: I have added the direction to take the medicine according to information provided in BNF instead of following the direction on prescription. Because i thought that mdu was not sufficient information for patient.

Name of medication: Diazepam 2mg tablet;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
This is because I have given the wrong directions on how patient should take their medication.

Possible cause/contributory factors: Carelessness

Reasons why incident occurred and actions required to prevent reoccurence:
I will confirm with the prescriber about the directions if I have queries about it in the future

Best description of this error/near miss:
wrong frequency

Date of incident: 10/01/2018

Error type: dispensing error

Patient age: 9

Patient sex: female

Brief summary of incident: incorrect dose on prescription went unnoticed

Name of medication: Trimethoprim suspension SF 50mg/5mL;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
The dose given was twice the correct dose and so would cause toxicity to the degree where side effects would be observed

Possible cause/contributory factors: Poor time management led to panicking and overseeing the obvious overdose

Reasons why incident occurred and actions required to prevent reoccurence:
More attention to detail and better time management in the future

Best description of this error/near miss:
wrong frequency

Date of incident: 17/01/2018

Error type: dispensing error

Patient age: 40

Patient sex: male

Brief summary of incident: Serious labelling error

Name of medication: Clarithromycin 250MG tablets;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
Two tablets twice daily is twice the correct dose resulting in an overdose and therefore extreme side effects may have been observed.

Possible cause/contributory factors: Poor time management resulted in a rush to produce the label which ended up with me entering incorrect instructions on the label

Reasons why incident occurred and actions required to prevent reoccurence:
Take care when entering the correct information on the labels including any BNF warning labels

Best description of this error/near miss:
wrong medicine label

Date of incident: 23/01/2018

Error type: near miss

Patient age: 45

Patient sex: male

Brief summary of incident: Wrong item dispensed. Contour Next Strips were dispensed, while the Rx was Contour test strips.

Name of medication: Contour Next Strips ;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
It is wrong product dispensed to the patient, the function of the product may different.

Possible cause/contributory factors: The glucose level measured may not accurate

Reasons why incident occurred and actions required to prevent reoccurence:
Double check the name of item when before dispensing the medicine

Best description of this error/near miss:
wrong product

Date of incident: 23/01/2018

Error type: dispensing error

Patient age: 40

Patient sex: female

Brief summary of incident: The BSO code of Activ Heal Foam adhesive dressing was not correct, The Activ Heal Hydrocolloid are not listed in the drug tariff and therefore are not allowed on the Rx.

Name of medication: Activ Heal Hydrocolloid dressing;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
The dressing is not allowed to dispensed.

Possible cause/contributory factors: The item that dispensed is not legal the law , because the dressing name is not stated in the drug tariff, means that the Activ Heal Hydrocolloid dressing is not allowed to dispensed.

Reasons why incident occurred and actions required to prevent reoccurence:
Read through the drug tariff carefully.

Best description of this error/near miss:
wrong method of preparation or supply

Date of incident: 30/01/2018

Error type: dispensing error

Patient age: 61

Patient sex: female

Brief summary of incident: Dispensed the wrong quantity of drug, dose was 1bd, so 56 would have been required for a 28 day supply, but only 28 tablets were given.

Name of medication: Pletal (cilostazol);

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
Patient would not be able to take the medication for 28 days.

Possible cause/contributory factors: I was spending too much time worrying if the change I made to the dose with the prescriber was the correct change to make.

Reasons why incident occurred and actions required to prevent reoccurence:
Always double check quantities, remember not to assume 28 days means 28 tablets.

Best description of this error/near miss:
wrong quantity

Date of incident: 30/01/2018

Error type: near miss

Patient age: 50

Patient sex: male

Brief summary of incident: the wholesale dealing required the qualification of doctor,if the script stated Dr Peter Lavery is not correct, it should be DR PETER LAVERY MB .

Name of medication: NITROMIN SPRAY 200 DOSE ; ASPIRIN DISPERSIBL

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
The form is not leggaly valid without the prescriber qualification .

Possible cause/contributory factors: The form is not leggaly valid without the prescriber qualification .

Reasons why incident occurred and actions required to prevent reoccurence:
Double check the legally check for wholesale dealing form in the future.

Best description of this error/near miss:
Legally check mistake

Date of incident: 30/01/2018

Error type: dispensing error

Patient age: 71

Patient sex: male

Brief summary of incident: The directions for atorvastatin was wrong. I incorrectly labelled it as "Take TWO tablets DAILY" instead of "Take ONE tablet DAILY". This therefore, resulted in a dosing error.

Name of medication: Atorvastatin 10 mg tablets;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
20 mg of statin would not cause fatal results but it still is an error and should be avoided as much as possible.

Possible cause/contributory factors: Distracted

Reasons why incident occurred and actions required to prevent reoccurence:
I will try my best to focus at the task and make sure to constantly check everything before dispensing it to the patient.

Best description of this error/near miss:
wrong dose strength

Date of incident: 10/01/2018

Error type: dispensing error

Patient age: James Leeson

Patient sex: male

Brief summary of incident: dispensed 250mg instead of 500mg tablets

Name of medication: amoxicilln tablets 250mg; amoxicillin tablets

Level of harm that could have occurred: 2

The reason you think the potential harm is at the level you have chosen:
due to the antibiotic being of a lower strength than intended, no harm would have came to the patient however it may not have treated the bacterial infection as intended

Possible cause/contributory factors: not clinically checking my product before dispensing

Reasons why incident occurred and actions required to prevent reoccurence:
perform a thorough clinical check of the item to be dispensed before dispensing, including reading the label

Best description of this error/near miss:
wrong dose strength

Date of incident: 19/01/2018

Error type: dispensing error

Patient age: 43

Patient sex: male

Brief summary of incident: Theophylline (Uniphyllin Continus) tablets were dispensed together with Erythromycin tablets. There is a serious interaction between these drugs which can result in reduced theophylline clearance, increasing theophylline plasma levels and leading to possible theophylline toxicity. The prescriber should have been asked to amend the prescription to either reduce the dose of erythromycin or change erythromycin to a suitable non interacting antibiotic (I.e. amoxicillin).

Name of medication: Theophylline (Uniphyllin); Erythromycin;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
Theophylline toxicity is very serious and can lead to serious harm including difficulty breathing and seizures.

Possible cause/contributory factors: Poor time management may have lead to me not assessing the severity of the interaction properly and therefore not taking appropriate action.

Reasons why incident occurred and actions required to prevent reoccurence:
Improve my time management and be more cautious when I receive prescriptions containing drugs that have many interactions or have narrow therapeutic windows which can lead to toxicity (i.e. warfarin, lithium, digoxin), so that I can take appropriate action to amend prescriptions if necessary.

Best description of this error/near miss:
interaction dispensed

Date of incident: 20/02/2018

Error type: dispensing error

Patient age: 54

Patient sex: female

Brief summary of incident: SCRIPT SAY TO TAKE EVERY 4-6 HOURS HOWEVER WHEN LOOKING QUICKLY ONLINE IT STATED THAT YOU COULD TAKE A MAXIMUM OF EIGHT .therfore patient recieved inappropriate advice which could lead to an overdose

Name of medication: dihydorcodeine 30mg tablets;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
opiates can cause respiratory depression , therfore could be fatal. Addictive

Possible cause/contributory factors: reading irrrelevant pil and not following the advice on the script

Reasons why incident occurred and actions required to prevent reoccurence:
reread what is on the script before dispensing , f needed calculate exactly how many tablets is needed in 24 hours

Best description of this error/near miss:
wrong dose strength
wrong frequency
verbal direction to patient wrong or omitted

Date of incident: 13/02/2018

Error type: dispensing error

Patient age: Elaine Erskine

Patient sex: female

Brief summary of incident: No ampoule size on requisition

Name of medication: Pethidine hydrochloride injection;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
Wrong strength could be given to patient

Possible cause/contributory factors: Strength could be wrong

Reasons why incident occurred and actions required to prevent reoccurence:
Check what ampoule size is available

Best description of this error/near miss:
wrong dose strength

Date of incident: 13/02/2018

Error type: dispensing error

Patient age: 45

Patient sex: female

Brief summary of incident: The prescription was for diamorphine hydrochloride 10mg powder for solution for injection ampoules, however the directions stated “give via syringe driver every 24 hours”. I failed to ask the prescriber to change this to “give ONE via syringe driver...” and so left the number of ampoules to be administered per dose ambiguous. This could have resulted in an overdose being given to the patient.

Name of medication: Diamorphine hydrochloride 10mg powder for solution

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
If more than one ampoule was administered in error to the patient in a single dose, this could have resulted in severe respiratory depression which could have resulted in death.

Possible cause/contributory factors: Feeling pressurised with time as I had already been to the prescriber twice about other issues. Thus I failed to realise that this also needed amended.

Reasons why incident occurred and actions required to prevent reoccurence:
I will better organise my time and stick to my checklist, write a list of all issues I wish to ask the prescriber about to avoid forgetting any and having to go multiple times.

Best description of this error/near miss:
wrong dose strength

Date of incident: 20/02/2018

Error type: dispensing error

Patient age: 7

Patient sex: male

Brief summary of incident: Quantity not in words and figures.

Name of medication: Ritalin 10mg tablets;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
Agreed dose for patient was correct with presciber before dispensing. As this is a schedule 2 drug, it is a legal requirement to have the quantity in words and figures.

Possible cause/contributory factors: Overlooked.

Reasons why incident occurred and actions required to prevent reoccurence:
Ensure prescriptions for schedule 2 and 3 control drugs have the quantity written in words and figures. I will be more thorough in my clinical checks and pay greater attention to detail.

Best description of this error/near miss:
Quantity not in words and figures for schedule 2 CD.

Date of incident: 14/02/2018

Error type: dispensing error

Patient age: 56

Patient sex: male

Brief summary of incident: Incorrect warning labels appeared on the label for the drug

Name of medication: fluoxetine;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
The computer system placed warning labels 3 and 21 on the label this puts unnecessary restrictions on the patient

Possible cause/contributory factors: Computer system is pre programmed to place certain labels on the label

Reasons why incident occurred and actions required to prevent reoccurence:
carefully check the label and remove any unnecessary labels

Best description of this error/near miss:
wrong warning labels

Date of incident: 14/02/2018

Error type: dispensing error

Patient age: N/A (Podiatrist)

Patient sex: male

Brief summary of incident: Script had no professional qualifications and Co-dydramol should not be given to a podiatrist

Name of medication: Co-dydramol;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
The script was not legally valid and should not have been given to the Podiatrist

Possible cause/contributory factors: Ran out of time in class

Reasons why incident occurred and actions required to prevent reoccurence:
Better time management. Do not spend so long on the first item to be dispensed

Best description of this error/near miss:
Not a legally valid requisition

Date of incident: 06/02/2019

Error type: dispensing error

Patient age: 11

Patient sex: male

Brief summary of incident: Tetracycline is not a suitable antibiotic to be given to children under 12 and is therefore contraindicated in this group. The Prescribed antibiotic should have been changed to a suitable alternative such as Amoxicillin.

Name of medication: Tetracycline 250mg;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
Deposition of tetracycline in growing bones and teeth by binding to calcium causing staining and potentially dental hypoplasia

Possible cause/contributory factors: Due to the presence of calcium in a child’s teeth and bones as the grow.

Reasons why incident occurred and actions required to prevent reoccurence:
Double check an antibiotic is suitable for the age group indicated on the prescription.

Best description of this error/near miss:
wrong product
contra-indication

Date of incident: 20/02/2019

Error type: dispensing error

Patient age: 51

Patient sex: female

Brief summary of incident: PCD1 form for sevredol tablets was wrongly repeated when Sch 2 controlled drugs cannot be repeated.

Name of medication: Sevredol 20mg tablets;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
This was the first dispensing of the repeat.

Possible cause/contributory factors: Knowledge of controlled drug legislation.

Reasons why incident occurred and actions required to prevent reoccurence:
Put note on my checklist. Remember schedules 2 and 3 controlled drugs can never be repeated.

Best description of this error/near miss:
Schedule 2 controlled drug repeated on PCD1 form.

Date of incident: 14/01/2020

Error type: dispensing error

Patient age: 10

Patient sex: female

Brief summary of incident: Dispensed suspension without shaking it first, places patient at risk.

Name of medication: Erythromycin Suspension 250mg/5mL;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
Patient could not receive drug meaning they would not receive the antibiotic.

Possible cause/contributory factors: Was not aware you had to shake the bottle to prevent sedimentation prior to dispensing, the patient was told to shake it before which I thought was enough.

Reasons why incident occurred and actions required to prevent reoccurence:
Always shake suspensions before dispensing.

Best description of this error/near miss:
Suspension not shaken.

Date of incident: 21/01/2020

Error type: dispensing error

Patient age: 71

Patient sex: male

Brief summary of incident: inappropiate counselling on nystatin. Told patient to use 1 drop four times a day instead of 1ml four times a day

Name of medication: nystatin oral suspension ;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
Patient was requiring nystatin for oral candidiasis. Infection most likely would not have went away given the counselling they were given. Patient would have had to return to the GP to receive another course of the antifungal to clear the infection.

Possible cause/contributory factors: Not familiarising myself with the product enough before counselling the patient

Reasons why incident occurred and actions required to prevent reoccurence:
I will ensure to read all the additional information that comes with the product before counselling a patient to ensure this does not happen again.

Best description of this error/near miss:
verbal direction to patient wrong or omitted

Date of incident: 15/01/2020

Error type: dispensing error

Patient age: 5 yrs 6 mths

Patient sex: female

Brief summary of incident: Dose for product on label was written as place one drop not 1mL

Name of medication: Nystatin oral suspension;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
Patient would not possibly take the correct dose

Possible cause/contributory factors: Did not consider the appropriate language to use when labelling

Reasons why incident occurred and actions required to prevent reoccurence:
Always use correct units of measurements when labelling as one drop is not appropriate

Best description of this error/near miss:
wrong dose strength

Date of incident: 11/02/2020

Error type: dispensing error

Patient age: -

Patient sex: male

Brief summary of incident: OSPE The wrong strength dispensed was not noticed. The insufficient form (tablet) was dispensed while midwives can only dispense parenteral. Wrong indication was not spotted. (due to IR and MR preparation)

Name of medication: morphine; pethidine;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
Wrong drug taken at wring interval can cause death in patient

Possible cause/contributory factors: careless mistake, not checking the clinical indication properly, not familiar with CD legislation

Reasons why incident occurred and actions required to prevent reoccurence:
read MEP for midwife section again, make a reminder note of diff preparation of tablets, check BNF carefully

Best description of this error/near miss:
wrong dose strength
wrong medication
wrong frequency
wrong route of administration

Date of incident: 14/01/2020

Error type: dispensing error

Patient age: N/A

Patient sex: female

Brief summary of incident: This was a wholesale deal to supply for use in the doctors practice however there was no qualifications and therefore was not legally valid

Name of medication: famvir 125mg tablets; rozex 0.75% gel;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
there was no patient involved however if this was a fake script i could have caused potential harm with medications in the wrong hands. the wholesale deal was not legal.

Possible cause/contributory factors: i wasnt area "dr" was not sufficient and qualifications are required.

Reasons why incident occurred and actions required to prevent reoccurence:
use a legal check list when checking requirements

Best description of this error/near miss:
legal requirement missing

Date of incident: 22/01/2020

Error type: dispensing error

Patient age: 64

Patient sex: male

Brief summary of incident: Incorrect strength of GTN tablets dispensed & Wrong quantity of Istin tablets dispensed.

Name of medication: Istin 5mg Tablets; GTN 300mcg sublingual tabl

Level of harm that could have occurred: 2

The reason you think the potential harm is at the level you have chosen:
It can cause hypotension at increased doses so therefore in elderly patients could lead to falls or injuries if they fall. May get some stomach upset symptoms also.

Possible cause/contributory factors: Rushing through the prescriptions without checking them against the products before bringing to the patient to dispense, I will make sure to take the time to do this in the future for the safety of the patient.

Reasons why incident occurred and actions required to prevent reoccurence:
Check the dispensed product against the prescription and the prescription against the label to ensure dispensing errors are minimised.

Best description of this error/near miss:
wrong dose strength
wrong quantity

Date of incident: 18/02/2020

Error type: dispensing error

Patient age: 58

Patient sex: male

Brief summary of incident: CD legally insufficient direction as mdu

Name of medication: Midazolam 10mg/2ml injection ampoules;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
Although injection will be administered by healthcare professionals, can possibly administered more than 1 ampoule at a time

Possible cause/contributory factors: not familiar with legal requirements of CD (thought information in brackets is equivalent as direction)

Reasons why incident occurred and actions required to prevent reoccurence:
write a note to remind direction must be written as __ as directed (__ = quantity)

Best description of this error/near miss:
wrong frequency

Date of incident: 04/02/2020

Error type: dispensing error

Patient age: 

Patient sex: female

Brief summary of incident: Directions for prednisolone in mg rather than the number of tablets Wrong quantity of prednisolone dispensed - 44 not 42 Unnecessary warning label - with GR formulations - do not need to take with food.

Name of medication: Prednisolone 5mg;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
The patient could have taken the dose as 30 tablets instead of 30mg dose - 6 tablets.

Possible cause/contributory factors: Unsure when you can change what is written on the label, instead of Rx.

Reasons why incident occurred and actions required to prevent reoccurence:
Ensure that when dispensing, to double count tablets. Also to reread label and ensure directions are clear.

Best description of this error/near miss:
wrong dose strength
wrong quantity

Date of incident: 26/02/2020

Error type: dispensing error

Patient age: 10

Patient sex: female

Brief summary of incident: Counselling on the maximum number of doses per day resulted in wrong guidance. Four times daily is not automatically accepted number of doses with a regimen of four to six hours.

Name of medication: Oxynorm 5mg/5ml SF Oral Solution;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
Pain could go uncontrolled leading to poor quality of life during palliative car.

Possible cause/contributory factors: Unsure of dosing guidelines for oxynorm.

Reasons why incident occurred and actions required to prevent reoccurence:
Need to take a more holistic approach re-pain levels recently as guidance

Best description of this error/near miss:
verbal direction to patient wrong or omitted

Date of incident: 19/01/2022

Error type: dispensing error

Patient age: 60

Patient sex: male

Brief summary of incident: Patient needs itraconazole while he is on simvastatin. Did not tell him that he can only start the simvastatin only 14 days after completing the course of the itraconazole.

Name of medication: Itraconazole; Simvastatin;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
myalgia, myopathy, but no death

Possible cause/contributory factors: not reading PIL properly

Reasons why incident occurred and actions required to prevent reoccurence:
fully reading the PIL

Best description of this error/near miss:
verbal direction to patient wrong or omitted
interaction dispensed

Date of incident: 12/01/2022

Error type: dispensing error

Patient age: 12

Patient sex: female

Brief summary of incident: Quantity to take on the labels were written as the dose in mg rather than the amount of spoonfuls to be taken. As required was also added to the label when it was not what the prescriber had prescribed. Shake the bottle well warning was also missing

Name of medication: Ibuprofen 100mg/5ml oral suspension s/f; Acic

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
The patient may have miscalculated how many spoonfuls to take and could have over or underdosed. If an overdose occurred, the patient could have gotten significantly ill.

Possible cause/contributory factors: Insufficient knowledge of labelling and no checklist created

Reasons why incident occurred and actions required to prevent reoccurence:
I will make sure that the label is always written in a patient friendly manner and will write a checklist to ensure that this will not happen again.

Best description of this error/near miss:
wrong dose strength
wrong medication
wrong frequency
wrong medicine label

Date of incident: 16/02/2022

Error type: dispensing error

Patient age: 69

Patient sex: female

Brief summary of incident: Morphine dose appropriateness not confirmed and was an extremely high and unsafe dose

Name of medication: Oramorph oral conc 20mg/ml;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
Patient would have went into respiratory depression

Possible cause/contributory factors: Mix up with prolonged release preparations

Reasons why incident occurred and actions required to prevent reoccurence:
Query high doses of opioids

Best description of this error/near miss:
wrong dose strength

Date of incident: 13/01/2023

Error type: dispensing error

Patient age: 3 years old

Patient sex: female

Brief summary of incident: Read the wrong part of the BNF in which I looked at the 400/57 suspension and not the 125/31 suspension which meant I dispensed a underdose as the medication should of been given 3 times a day and not the 2 times a day I dispensed

Name of medication: Co-amoxiclav ;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
Patients infection would not of cleared and subsequently the patients carer would need to take her back to the doctors to receive more treatment

Possible cause/contributory factors: First assessed dispensing class meaning nerves got the better of me

Reasons why incident occurred and actions required to prevent reoccurence:
I will now check the BNF and the emc to determine the correct dosing regime. Additionally, I will take deep breaths before the class in order to enable me to calm myself.

Best description of this error/near miss:
wrong frequency

Date of incident: 11/01/2023

Error type: dispensing error

Patient age: 11

Patient sex: female

Brief summary of incident: An underdose of a antibiotic and NSAID was provided to the patient

Name of medication: Co-amoxiclav; Ibuprofen;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
The patient would have received insufficient pain relief and the infection would have not been cleared up and therefore the infection could get worse. But since its was a oral infection long term harm or death may be avoided.

Possible cause/contributory factors: The clinical check was carried out incorrectly therefore the errors on the prescription was not noticed.

Reasons why incident occurred and actions required to prevent reoccurence:
Be able to identify the indication of the prescribed medication accurately using the appropriate resources and identify errors on a prescription and correct it to the correct standard.

Best description of this error/near miss:
wrong dose strength
wrong frequency

Date of incident: 11/01/2023

Error type: dispensing error

Patient age: 5y 6mth

Patient sex: female

Brief summary of incident: Serious labelling error: frequency of nystatin dose not outlined on label. Nystatin label was placed on box Issues relating to sugar-free ibuprofen oral suspension: s/f dispensed but not on script or label

Name of medication: Nystatin; Ibuprofen;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
Nystatin could have been given in over- or under-dose, as no frequency was outlined, which may have caused the patient harm as a result of overdose, or may not have resolved the infection which was being treated.

Possible cause/contributory factors: First assessed class and was focussing on timing too much - need to relax and stick to the SOPs

Reasons why incident occurred and actions required to prevent reoccurence:
Revise SOPs to highlight checking labels against prescription directions to avoid serious omissions. Ensure prescriber specifies sugar-free/flavour where necessary (be more prepared for alternative suggestions to unsuitable drugs)

Best description of this error/near miss:
wrong frequency
medicine omitted
wrong medicine label
wrong product

Date of incident: 13/01/2023

Error type: dispensing error

Patient age: 81

Patient sex: female

Brief summary of incident: Wrong patient name on label Not querying size of dressing with prescriber

Name of medication: Askina Carbosorb; Metronidazole ;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
Wrong patient name on label can result in harmful effects if given to wrong patient.

Possible cause/contributory factors: Carelessness

Reasons why incident occurred and actions required to prevent reoccurence:
Double check label, patient information and carefully undergo clinical check.

Best description of this error/near miss:
wrong dose strength
mismatch

Date of incident: 18/01/2023

Error type: dispensing error

Patient age: 51

Patient sex: female

Brief summary of incident: Label for nicorandil stated; "Take one 25mg tablet daily". 10mg tablets were dispensed so the patient is going to attempt take 2 and a half 10mg tablets to make the dose. The frequency should have been for the 10mg tablets bd.

Name of medication: Nicorandil 10mg tablets;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
The patient would have tried to take two and a half tablets to make the 25mg dose.

Possible cause/contributory factors: Not double-checking strength of tablets.

Reasons why incident occurred and actions required to prevent reoccurence:
Take more care in ensuring correct strength of tablets dispensed.

Best description of this error/near miss:
wrong dose strength
wrong frequency

Date of incident: 1/02/2023

Error type: dispensing error

Patient age: 71

Patient sex: female

Brief summary of incident: Incorrect dosage instructions on label

Name of medication: Oxis 12mcg/dose turbhohale;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
overdose

Possible cause/contributory factors: Not referring back to Prescription carefully enough when doing label

Reasons why incident occurred and actions required to prevent reoccurence:
double check what is written on prescription matches what is on dispensing label

Best description of this error/near miss:
wrong frequency

Date of incident: 18/01/2023

Error type: dispensing error

Patient age: 64

Patient sex: male

Brief summary of incident: Advised the patient to wait one week before seeking help if glyceryl trinitrate spray not resolving angina symptoms and patient was therefore placed at serious risk .

Name of medication: Glyceryl trinitrate spray ;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
The patient could have die from a cardiac incident had they waited this long

Possible cause/contributory factors: Lack of consideration on the safe use of medicines

Reasons why incident occurred and actions required to prevent reoccurence:
Take more time to consider the specific condition indicated and the safe use of medicines surrounding it.

Best description of this error/near miss:
verbal direction to patient wrong or omitted

Date of incident: 03/02/2023

Error type: dispensing error

Patient age: 9 years 2 months

Patient sex: male

Brief summary of incident: Did not query the strength of the inhaler and missed out BNF warning labels on dispensed product label

Name of medication: Phenoxymethylpenicillin; Clenil Modulite CFC

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
Wrong dose and strength of inhaler given and insufficient warning labels can harm the patient.

Possible cause/contributory factors: Carelessness

Reasons why incident occurred and actions required to prevent reoccurence:
Work through my framework, double check dispensed product and clarify any doubts with the prescriber.

Best description of this error/near miss:
wrong dose strength