Date of incident: 15/01/2020

Error type: dispensing error

Patient age: 5 yrs 6 mths

Patient sex: female

Brief summary of incident: Dose for product on label was written as place one drop not 1mL

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 would not possibly take the correct dose

Possible cause/contributory factors: Did not consider the appropriate language to use when labelling

Reasons why incident occurred and actions required to prevent reoccurence:
Always use correct units of measurements when labelling as one drop is not appropriate

Best description of this error/near miss:
wrong dose strength