Incident Log
Date of incident: 29/01/2013
Error type: dispensing error
Patient age: 4
Patient sex: male
Brief summary of incident: spacer with infant mask prescribed and dispensed when the patient is a child
Name of medication: Aerochamber plus with infant mask; Miconazole
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
The patient would have been left without a spacer device to use with their inhaler. The worst case scenario would have been death due to the chance that the patient may have missed doses of their corticosteroid inhaler leading to an acute exacerbation of asthma.
Possible cause/contributory factors: Too focused on other item prescribed. I was too presumptuous that spacer device may still be suitable.
Reasons why incident occurred and actions required to prevent reoccurence:
Question anything that I feel could be an issue in the future when dispensing.
Best description of this error/near miss:
wrong product
Error type: dispensing error
Patient age: 4
Patient sex: male
Brief summary of incident: spacer with infant mask prescribed and dispensed when the patient is a child
Name of medication: Aerochamber plus with infant mask; Miconazole
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
The patient would have been left without a spacer device to use with their inhaler. The worst case scenario would have been death due to the chance that the patient may have missed doses of their corticosteroid inhaler leading to an acute exacerbation of asthma.
Possible cause/contributory factors: Too focused on other item prescribed. I was too presumptuous that spacer device may still be suitable.
Reasons why incident occurred and actions required to prevent reoccurence:
Question anything that I feel could be an issue in the future when dispensing.
Best description of this error/near miss:
wrong product