Incident Log
Date of incident: 22/01/2020
Error type: dispensing error
Patient age: 64
Patient sex: male
Brief summary of incident: Incorrect strength of GTN tablets dispensed & Wrong quantity of Istin tablets dispensed.
Name of medication: Istin 5mg Tablets; GTN 300mcg sublingual tabl
Level of harm that could have occurred: 2
The reason you think the potential harm is at the level you have chosen:
It can cause hypotension at increased doses so therefore in elderly patients could lead to falls or injuries if they fall. May get some stomach upset symptoms also.
Possible cause/contributory factors: Rushing through the prescriptions without checking them against the products before bringing to the patient to dispense, I will make sure to take the time to do this in the future for the safety of the patient.
Reasons why incident occurred and actions required to prevent reoccurence:
Check the dispensed product against the prescription and the prescription against the label to ensure dispensing errors are minimised.
Best description of this error/near miss:
wrong dose strength
wrong quantity
Error type: dispensing error
Patient age: 64
Patient sex: male
Brief summary of incident: Incorrect strength of GTN tablets dispensed & Wrong quantity of Istin tablets dispensed.
Name of medication: Istin 5mg Tablets; GTN 300mcg sublingual tabl
Level of harm that could have occurred: 2
The reason you think the potential harm is at the level you have chosen:
It can cause hypotension at increased doses so therefore in elderly patients could lead to falls or injuries if they fall. May get some stomach upset symptoms also.
Possible cause/contributory factors: Rushing through the prescriptions without checking them against the products before bringing to the patient to dispense, I will make sure to take the time to do this in the future for the safety of the patient.
Reasons why incident occurred and actions required to prevent reoccurence:
Check the dispensed product against the prescription and the prescription against the label to ensure dispensing errors are minimised.
Best description of this error/near miss:
wrong dose strength
wrong quantity