Date of incident: 1/02/2023

Error type: dispensing error

Patient age: 71

Patient sex: female

Brief summary of incident: Incorrect dosage instructions on label

Name of medication: Oxis 12mcg/dose turbhohale;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
overdose

Possible cause/contributory factors: Not referring back to Prescription carefully enough when doing label

Reasons why incident occurred and actions required to prevent reoccurence:
double check what is written on prescription matches what is on dispensing label

Best description of this error/near miss:
wrong frequency