Date of incident: 03/02/2023

Error type: dispensing error

Patient age: 9 years 2 months

Patient sex: male

Brief summary of incident: Did not query the strength of the inhaler and missed out BNF warning labels on dispensed product label

Name of medication: Phenoxymethylpenicillin; Clenil Modulite CFC

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
Wrong dose and strength of inhaler given and insufficient warning labels can harm the patient.

Possible cause/contributory factors: Carelessness

Reasons why incident occurred and actions required to prevent reoccurence:
Work through my framework, double check dispensed product and clarify any doubts with the prescriber.

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