Incident Log
Date of incident: 18/01/2023
Error type: dispensing error
Patient age: 51
Patient sex: female
Brief summary of incident: Label for nicorandil stated; "Take one 25mg tablet daily". 10mg tablets were dispensed so the patient is going to attempt take 2 and a half 10mg tablets to make the dose. The frequency should have been for the 10mg tablets bd.
Name of medication: Nicorandil 10mg tablets;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
The patient would have tried to take two and a half tablets to make the 25mg dose.
Possible cause/contributory factors: Not double-checking strength of tablets.
Reasons why incident occurred and actions required to prevent reoccurence:
Take more care in ensuring correct strength of tablets dispensed.
Best description of this error/near miss:
wrong dose strength
wrong frequency
Error type: dispensing error
Patient age: 51
Patient sex: female
Brief summary of incident: Label for nicorandil stated; "Take one 25mg tablet daily". 10mg tablets were dispensed so the patient is going to attempt take 2 and a half 10mg tablets to make the dose. The frequency should have been for the 10mg tablets bd.
Name of medication: Nicorandil 10mg tablets;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
The patient would have tried to take two and a half tablets to make the 25mg dose.
Possible cause/contributory factors: Not double-checking strength of tablets.
Reasons why incident occurred and actions required to prevent reoccurence:
Take more care in ensuring correct strength of tablets dispensed.
Best description of this error/near miss:
wrong dose strength
wrong frequency