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