Incident Log
Date of incident: 11/02/2020
Error type: dispensing error
Patient age: -
Patient sex: male
Brief summary of incident: OSPE The wrong strength dispensed was not noticed. The insufficient form (tablet) was dispensed while midwives can only dispense parenteral. Wrong indication was not spotted. (due to IR and MR preparation)
Name of medication: morphine; pethidine;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
Wrong drug taken at wring interval can cause death in patient
Possible cause/contributory factors: careless mistake, not checking the clinical indication properly, not familiar with CD legislation
Reasons why incident occurred and actions required to prevent reoccurence:
read MEP for midwife section again, make a reminder note of diff preparation of tablets, check BNF carefully
Best description of this error/near miss:
wrong dose strength
wrong medication
wrong frequency
wrong route of administration
Error type: dispensing error
Patient age: -
Patient sex: male
Brief summary of incident: OSPE The wrong strength dispensed was not noticed. The insufficient form (tablet) was dispensed while midwives can only dispense parenteral. Wrong indication was not spotted. (due to IR and MR preparation)
Name of medication: morphine; pethidine;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
Wrong drug taken at wring interval can cause death in patient
Possible cause/contributory factors: careless mistake, not checking the clinical indication properly, not familiar with CD legislation
Reasons why incident occurred and actions required to prevent reoccurence:
read MEP for midwife section again, make a reminder note of diff preparation of tablets, check BNF carefully
Best description of this error/near miss:
wrong dose strength
wrong medication
wrong frequency
wrong route of administration