Incident Log
Date of incident: 13/02/2018
Error type: dispensing error
Patient age: 45
Patient sex: female
Brief summary of incident: The prescription was for diamorphine hydrochloride 10mg powder for solution for injection ampoules, however the directions stated “give via syringe driver every 24 hours”. I failed to ask the prescriber to change this to “give ONE via syringe driver...” and so left the number of ampoules to be administered per dose ambiguous. This could have resulted in an overdose being given to the patient.
Name of medication: Diamorphine hydrochloride 10mg powder for solution
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
If more than one ampoule was administered in error to the patient in a single dose, this could have resulted in severe respiratory depression which could have resulted in death.
Possible cause/contributory factors: Feeling pressurised with time as I had already been to the prescriber twice about other issues. Thus I failed to realise that this also needed amended.
Reasons why incident occurred and actions required to prevent reoccurence:
I will better organise my time and stick to my checklist, write a list of all issues I wish to ask the prescriber about to avoid forgetting any and having to go multiple times.
Best description of this error/near miss:
wrong dose strength
Error type: dispensing error
Patient age: 45
Patient sex: female
Brief summary of incident: The prescription was for diamorphine hydrochloride 10mg powder for solution for injection ampoules, however the directions stated “give via syringe driver every 24 hours”. I failed to ask the prescriber to change this to “give ONE via syringe driver...” and so left the number of ampoules to be administered per dose ambiguous. This could have resulted in an overdose being given to the patient.
Name of medication: Diamorphine hydrochloride 10mg powder for solution
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
If more than one ampoule was administered in error to the patient in a single dose, this could have resulted in severe respiratory depression which could have resulted in death.
Possible cause/contributory factors: Feeling pressurised with time as I had already been to the prescriber twice about other issues. Thus I failed to realise that this also needed amended.
Reasons why incident occurred and actions required to prevent reoccurence:
I will better organise my time and stick to my checklist, write a list of all issues I wish to ask the prescriber about to avoid forgetting any and having to go multiple times.
Best description of this error/near miss:
wrong dose strength