Incident Log
Date of incident: 06/02/2013
Error type: dispensing error
Patient age: 65
Patient sex: female
Brief summary of incident: Medication supplied in an unlabelled box
Name of medication: Digoxin 125mcg Tab;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
As the box was unlabelled, the patient might be taking the wrong amount of tablet which can lead to underdose or overdose. The patient might not get the therapeutic effect and on the other hand, he might get high digoxin toxicity which can he harmful to him.
Possible cause/contributory factors: Poor time management and rushed in to the products in time.
Reasons why incident occurred and actions required to prevent reoccurence:
Should have made the final check before handing in the product to the patient as well as follow SOP framework.
Best description of this error/near miss:
wrong medicine label
Error type: dispensing error
Patient age: 65
Patient sex: female
Brief summary of incident: Medication supplied in an unlabelled box
Name of medication: Digoxin 125mcg Tab;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
As the box was unlabelled, the patient might be taking the wrong amount of tablet which can lead to underdose or overdose. The patient might not get the therapeutic effect and on the other hand, he might get high digoxin toxicity which can he harmful to him.
Possible cause/contributory factors: Poor time management and rushed in to the products in time.
Reasons why incident occurred and actions required to prevent reoccurence:
Should have made the final check before handing in the product to the patient as well as follow SOP framework.
Best description of this error/near miss:
wrong medicine label