Incident Log
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
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