Incident Log
Date of incident: 06/02/2013
Error type: near miss
Patient age: 71
Patient sex: male
Brief summary of incident: Misread on the prescription S/L as S/R for GTN tablets and got the strength ammended to an incorrect value.
Name of medication: Glyceryl trinitrate;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
If the form that I had the prescription ammended to had been dispensed, ie the modified release buccal form instead of the sublingual form, the patient would have been taking two modified release nitrates. This would have been an overdose of nitrates and could have a fatal outcome.
Possible cause/contributory factors: Not taking enough care when reading the prescription.
Reasons why incident occurred and actions required to prevent reoccurence:
Double check the prescription before contacting the prescriber.
Best description of this error/near miss:
wrong medication
Error type: near miss
Patient age: 71
Patient sex: male
Brief summary of incident: Misread on the prescription S/L as S/R for GTN tablets and got the strength ammended to an incorrect value.
Name of medication: Glyceryl trinitrate;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
If the form that I had the prescription ammended to had been dispensed, ie the modified release buccal form instead of the sublingual form, the patient would have been taking two modified release nitrates. This would have been an overdose of nitrates and could have a fatal outcome.
Possible cause/contributory factors: Not taking enough care when reading the prescription.
Reasons why incident occurred and actions required to prevent reoccurence:
Double check the prescription before contacting the prescriber.
Best description of this error/near miss:
wrong medication