Date of incident: 14/01/2020

Error type: dispensing error

Patient age: 10

Patient sex: female

Brief summary of incident: Dispensed suspension without shaking it first, places patient at risk.

Name of medication: Erythromycin Suspension 250mg/5mL;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
Patient could not receive drug meaning they would not receive the antibiotic.

Possible cause/contributory factors: Was not aware you had to shake the bottle to prevent sedimentation prior to dispensing, the patient was told to shake it before which I thought was enough.

Reasons why incident occurred and actions required to prevent reoccurence:
Always shake suspensions before dispensing.

Best description of this error/near miss:
Suspension not shaken.