Incident Log
Date of incident: 04/02/2020
Error type: dispensing error
Patient age:
Patient sex: female
Brief summary of incident: Directions for prednisolone in mg rather than the number of tablets Wrong quantity of prednisolone dispensed - 44 not 42 Unnecessary warning label - with GR formulations - do not need to take with food.
Name of medication: Prednisolone 5mg;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
The patient could have taken the dose as 30 tablets instead of 30mg dose - 6 tablets.
Possible cause/contributory factors: Unsure when you can change what is written on the label, instead of Rx.
Reasons why incident occurred and actions required to prevent reoccurence:
Ensure that when dispensing, to double count tablets. Also to reread label and ensure directions are clear.
Best description of this error/near miss:
wrong dose strength
wrong quantity
Error type: dispensing error
Patient age:
Patient sex: female
Brief summary of incident: Directions for prednisolone in mg rather than the number of tablets Wrong quantity of prednisolone dispensed - 44 not 42 Unnecessary warning label - with GR formulations - do not need to take with food.
Name of medication: Prednisolone 5mg;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
The patient could have taken the dose as 30 tablets instead of 30mg dose - 6 tablets.
Possible cause/contributory factors: Unsure when you can change what is written on the label, instead of Rx.
Reasons why incident occurred and actions required to prevent reoccurence:
Ensure that when dispensing, to double count tablets. Also to reread label and ensure directions are clear.
Best description of this error/near miss:
wrong dose strength
wrong quantity