Incident Log
Date of incident: 11/02/2013
Error type: dispensing error
Patient age: 43
Patient sex: male
Brief summary of incident: The wrong directions were put on the label of methotrexate - the directions on the label should have been weekly (as per the prescription), but the label read "Take ONE daily".
Name of medication: Methotrexate;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
Methotrexate is highly toxic at the dosage frequency given and hence is likely to cause serious injury or death.
Possible cause/contributory factors: The other item I was dispensing was a "Take ONE daily" dose; I got mixed up between the two items and under time-pressure for dispensing, made the error.
Reasons why incident occurred and actions required to prevent reoccurence:
I failed to follow my SOP for dispensing an NHS prescription from a GP and also failed to make the checks outlined in my personal checking framework. I should have checked the label matched the prescription directions, as I had already made my clinical checks on the prescription - I will ensure this happens in the future. I will also develop an SOP for dispensing methotrexate as it is a medicine associated with a high level of potential risk to the patient.
Best description of this error/near miss:
wrong frequency
wrong medicine label
Error type: dispensing error
Patient age: 43
Patient sex: male
Brief summary of incident: The wrong directions were put on the label of methotrexate - the directions on the label should have been weekly (as per the prescription), but the label read "Take ONE daily".
Name of medication: Methotrexate;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
Methotrexate is highly toxic at the dosage frequency given and hence is likely to cause serious injury or death.
Possible cause/contributory factors: The other item I was dispensing was a "Take ONE daily" dose; I got mixed up between the two items and under time-pressure for dispensing, made the error.
Reasons why incident occurred and actions required to prevent reoccurence:
I failed to follow my SOP for dispensing an NHS prescription from a GP and also failed to make the checks outlined in my personal checking framework. I should have checked the label matched the prescription directions, as I had already made my clinical checks on the prescription - I will ensure this happens in the future. I will also develop an SOP for dispensing methotrexate as it is a medicine associated with a high level of potential risk to the patient.
Best description of this error/near miss:
wrong frequency
wrong medicine label