Date of incident: 11/01/2023

Error type: dispensing error

Patient age: 11

Patient sex: female

Brief summary of incident: An underdose of a antibiotic and NSAID was provided to the patient

Name of medication: Co-amoxiclav; Ibuprofen;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
The patient would have received insufficient pain relief and the infection would have not been cleared up and therefore the infection could get worse. But since its was a oral infection long term harm or death may be avoided.

Possible cause/contributory factors: The clinical check was carried out incorrectly therefore the errors on the prescription was not noticed.

Reasons why incident occurred and actions required to prevent reoccurence:
Be able to identify the indication of the prescribed medication accurately using the appropriate resources and identify errors on a prescription and correct it to the correct standard.

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