Date of incident: 20/02/2019

Error type: dispensing error

Patient age: 51

Patient sex: female

Brief summary of incident: PCD1 form for sevredol tablets was wrongly repeated when Sch 2 controlled drugs cannot be repeated.

Name of medication: Sevredol 20mg tablets;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
This was the first dispensing of the repeat.

Possible cause/contributory factors: Knowledge of controlled drug legislation.

Reasons why incident occurred and actions required to prevent reoccurence:
Put note on my checklist. Remember schedules 2 and 3 controlled drugs can never be repeated.

Best description of this error/near miss:
Schedule 2 controlled drug repeated on PCD1 form.