Incident Log
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
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