Incident Log
Date of incident: 19/01/2018
Error type: dispensing error
Patient age: 43
Patient sex: male
Brief summary of incident: Theophylline (Uniphyllin Continus) tablets were dispensed together with Erythromycin tablets. There is a serious interaction between these drugs which can result in reduced theophylline clearance, increasing theophylline plasma levels and leading to possible theophylline toxicity. The prescriber should have been asked to amend the prescription to either reduce the dose of erythromycin or change erythromycin to a suitable non interacting antibiotic (I.e. amoxicillin).
Name of medication: Theophylline (Uniphyllin); Erythromycin;
Level of harm that could have occurred: 4
The reason you think the potential harm is at the level you have chosen:
Theophylline toxicity is very serious and can lead to serious harm including difficulty breathing and seizures.
Possible cause/contributory factors: Poor time management may have lead to me not assessing the severity of the interaction properly and therefore not taking appropriate action.
Reasons why incident occurred and actions required to prevent reoccurence:
Improve my time management and be more cautious when I receive prescriptions containing drugs that have many interactions or have narrow therapeutic windows which can lead to toxicity (i.e. warfarin, lithium, digoxin), so that I can take appropriate action to amend prescriptions if necessary.
Best description of this error/near miss:
interaction dispensed
Error type: dispensing error
Patient age: 43
Patient sex: male
Brief summary of incident: Theophylline (Uniphyllin Continus) tablets were dispensed together with Erythromycin tablets. There is a serious interaction between these drugs which can result in reduced theophylline clearance, increasing theophylline plasma levels and leading to possible theophylline toxicity. The prescriber should have been asked to amend the prescription to either reduce the dose of erythromycin or change erythromycin to a suitable non interacting antibiotic (I.e. amoxicillin).
Name of medication: Theophylline (Uniphyllin); Erythromycin;
Level of harm that could have occurred: 4
The reason you think the potential harm is at the level you have chosen:
Theophylline toxicity is very serious and can lead to serious harm including difficulty breathing and seizures.
Possible cause/contributory factors: Poor time management may have lead to me not assessing the severity of the interaction properly and therefore not taking appropriate action.
Reasons why incident occurred and actions required to prevent reoccurence:
Improve my time management and be more cautious when I receive prescriptions containing drugs that have many interactions or have narrow therapeutic windows which can lead to toxicity (i.e. warfarin, lithium, digoxin), so that I can take appropriate action to amend prescriptions if necessary.
Best description of this error/near miss:
interaction dispensed