Incident Log
Date of incident: 06/02/2019
Error type: dispensing error
Patient age: 11
Patient sex: male
Brief summary of incident: Tetracycline is not a suitable antibiotic to be given to children under 12 and is therefore contraindicated in this group. The Prescribed antibiotic should have been changed to a suitable alternative such as Amoxicillin.
Name of medication: Tetracycline 250mg;
Level of harm that could have occurred: 4
The reason you think the potential harm is at the level you have chosen:
Deposition of tetracycline in growing bones and teeth by binding to calcium causing staining and potentially dental hypoplasia
Possible cause/contributory factors: Due to the presence of calcium in a child’s teeth and bones as the grow.
Reasons why incident occurred and actions required to prevent reoccurence:
Double check an antibiotic is suitable for the age group indicated on the prescription.
Best description of this error/near miss:
wrong product
contra-indication
Error type: dispensing error
Patient age: 11
Patient sex: male
Brief summary of incident: Tetracycline is not a suitable antibiotic to be given to children under 12 and is therefore contraindicated in this group. The Prescribed antibiotic should have been changed to a suitable alternative such as Amoxicillin.
Name of medication: Tetracycline 250mg;
Level of harm that could have occurred: 4
The reason you think the potential harm is at the level you have chosen:
Deposition of tetracycline in growing bones and teeth by binding to calcium causing staining and potentially dental hypoplasia
Possible cause/contributory factors: Due to the presence of calcium in a child’s teeth and bones as the grow.
Reasons why incident occurred and actions required to prevent reoccurence:
Double check an antibiotic is suitable for the age group indicated on the prescription.
Best description of this error/near miss:
wrong product
contra-indication