Date of incident: 11/01/2023

Error type: dispensing error

Patient age: 5y 6mth

Patient sex: female

Brief summary of incident: Serious labelling error: frequency of nystatin dose not outlined on label. Nystatin label was placed on box Issues relating to sugar-free ibuprofen oral suspension: s/f dispensed but not on script or label

Name of medication: Nystatin; Ibuprofen;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
Nystatin could have been given in over- or under-dose, as no frequency was outlined, which may have caused the patient harm as a result of overdose, or may not have resolved the infection which was being treated.

Possible cause/contributory factors: First assessed class and was focussing on timing too much - need to relax and stick to the SOPs

Reasons why incident occurred and actions required to prevent reoccurence:
Revise SOPs to highlight checking labels against prescription directions to avoid serious omissions. Ensure prescriber specifies sugar-free/flavour where necessary (be more prepared for alternative suggestions to unsuitable drugs)

Best description of this error/near miss:
wrong frequency
medicine omitted
wrong medicine label
wrong product