Date of incident: 21/01/2020

Error type: dispensing error

Patient age: 71

Patient sex: male

Brief summary of incident: inappropiate counselling on nystatin. Told patient to use 1 drop four times a day instead of 1ml four times a day

Name of medication: nystatin oral suspension ;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
Patient was requiring nystatin for oral candidiasis. Infection most likely would not have went away given the counselling they were given. Patient would have had to return to the GP to receive another course of the antifungal to clear the infection.

Possible cause/contributory factors: Not familiarising myself with the product enough before counselling the patient

Reasons why incident occurred and actions required to prevent reoccurence:
I will ensure to read all the additional information that comes with the product before counselling a patient to ensure this does not happen again.

Best description of this error/near miss:
verbal direction to patient wrong or omitted