Date of incident: 18/02/2020

Error type: dispensing error

Patient age: 58

Patient sex: male

Brief summary of incident: CD legally insufficient direction as mdu

Name of medication: Midazolam 10mg/2ml injection ampoules;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
Although injection will be administered by healthcare professionals, can possibly administered more than 1 ampoule at a time

Possible cause/contributory factors: not familiar with legal requirements of CD (thought information in brackets is equivalent as direction)

Reasons why incident occurred and actions required to prevent reoccurence:
write a note to remind direction must be written as __ as directed (__ = quantity)

Best description of this error/near miss:
wrong frequency