Incident Log
Date of incident: 11/02/2013
Error type: near miss
Patient age: 23
Patient sex: female
Brief summary of incident: I was in the middle of dispensing an item when I realised there was no patient information leaflet in the packaging
Name of medication: Ventolin Evohaler;
Level of harm that could have occurred: 1
The reason you think the potential harm is at the level you have chosen:
The patient had been using the inhaler safely for a long time and was very familiar with it. Hence, it is unlikely that any harm would have come as a result of no PIL being given with the inhaler.
Possible cause/contributory factors: I had taken the PIL out to review the medicine and had forgotten to place it back in the packaging
Reasons why incident occurred and actions required to prevent reoccurence:
I will modify my personal checking framework to ensure that a check for a PIL is incorporate before the item is brought to the counter for dispensing.
Best description of this error/near miss:
PIL wrong or omitted
Error type: near miss
Patient age: 23
Patient sex: female
Brief summary of incident: I was in the middle of dispensing an item when I realised there was no patient information leaflet in the packaging
Name of medication: Ventolin Evohaler;
Level of harm that could have occurred: 1
The reason you think the potential harm is at the level you have chosen:
The patient had been using the inhaler safely for a long time and was very familiar with it. Hence, it is unlikely that any harm would have come as a result of no PIL being given with the inhaler.
Possible cause/contributory factors: I had taken the PIL out to review the medicine and had forgotten to place it back in the packaging
Reasons why incident occurred and actions required to prevent reoccurence:
I will modify my personal checking framework to ensure that a check for a PIL is incorporate before the item is brought to the counter for dispensing.
Best description of this error/near miss:
PIL wrong or omitted