Incident Log
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.
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.