Date of incident: 12/01/2022

Error type: dispensing error

Patient age: 12

Patient sex: female

Brief summary of incident: Quantity to take on the labels were written as the dose in mg rather than the amount of spoonfuls to be taken. As required was also added to the label when it was not what the prescriber had prescribed. Shake the bottle well warning was also missing

Name of medication: Ibuprofen 100mg/5ml oral suspension s/f; Acic

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
The patient may have miscalculated how many spoonfuls to take and could have over or underdosed. If an overdose occurred, the patient could have gotten significantly ill.

Possible cause/contributory factors: Insufficient knowledge of labelling and no checklist created

Reasons why incident occurred and actions required to prevent reoccurence:
I will make sure that the label is always written in a patient friendly manner and will write a checklist to ensure that this will not happen again.

Best description of this error/near miss:
wrong dose strength
wrong medication
wrong frequency
wrong medicine label