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