Incident Log
Date of incident: 20/02/2018
Error type: dispensing error
Patient age: 54
Patient sex: female
Brief summary of incident: SCRIPT SAY TO TAKE EVERY 4-6 HOURS HOWEVER WHEN LOOKING QUICKLY ONLINE IT STATED THAT YOU COULD TAKE A MAXIMUM OF EIGHT .therfore patient recieved inappropriate advice which could lead to an overdose
Name of medication: dihydorcodeine 30mg tablets;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
opiates can cause respiratory depression , therfore could be fatal. Addictive
Possible cause/contributory factors: reading irrrelevant pil and not following the advice on the script
Reasons why incident occurred and actions required to prevent reoccurence:
reread what is on the script before dispensing , f needed calculate exactly how many tablets is needed in 24 hours
Best description of this error/near miss:
wrong dose strength
wrong frequency
verbal direction to patient wrong or omitted
Error type: dispensing error
Patient age: 54
Patient sex: female
Brief summary of incident: SCRIPT SAY TO TAKE EVERY 4-6 HOURS HOWEVER WHEN LOOKING QUICKLY ONLINE IT STATED THAT YOU COULD TAKE A MAXIMUM OF EIGHT .therfore patient recieved inappropriate advice which could lead to an overdose
Name of medication: dihydorcodeine 30mg tablets;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
opiates can cause respiratory depression , therfore could be fatal. Addictive
Possible cause/contributory factors: reading irrrelevant pil and not following the advice on the script
Reasons why incident occurred and actions required to prevent reoccurence:
reread what is on the script before dispensing , f needed calculate exactly how many tablets is needed in 24 hours
Best description of this error/near miss:
wrong dose strength
wrong frequency
verbal direction to patient wrong or omitted