Date of incident: 13/2/2013

Error type: dispensing error

Patient age: 67

Patient sex: male

Brief summary of incident: Directions on prescription were " ii tid" This was misread was Take ONE THREE times DAILY when it should of been Take TWO THEE times DAILY

Name of medication: Praxilene 100mg Capsules ;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
Due to the error, the wrong directions were put on the label and the wrong quantity of capsules were supplied to the patient which would of provided a sub-therapeutic activity of the drug.

Possible cause/contributory factors: I was rushing and simply scanned the directions assuming it was " i tid"

Reasons why incident occurred and actions required to prevent reoccurence:
When unsure about what directions mean it is best to talk to the prescriber to clarify the situation.

Best description of this error/near miss:
wrong frequency