Incident Log
Date of incident: 29/01/2013
Error type: dispensing error
Patient age: 63
Patient sex: male
Brief summary of incident: Wrong form of inhaler dispensed, prescription stated Qvar autohaler but I dispensed Qvar aerosol. Furthermore the prescription stated 1 puff 3-4 times daily, this is the wrong dose for a steroid inhaler and thus should have been brought to the attention of the prescriber
Name of medication: Qvar 100mcg Autohaler;
Level of harm that could have occurred: 4
The reason you think the potential harm is at the level you have chosen:
There is a likelihood that the patient cannot use a pMDI inhaler effectively and thus had been prescribed an autohaler for this reason and thus his asthma would not sufficiently be controlled. Furthermore this is an overdose, however still not a high dose of inhaled corticosteroid could still potentially have adverse effects and further predispose the patient to oral candidaisis.
Possible cause/contributory factors: Under pressure I did not perform the clinical check of the prescription properly.
Reasons why incident occurred and actions required to prevent reoccurence:
Taking more time, care and having a better checking framework is needed to overcome such errors
Best description of this error/near miss:
wrong medication
wrong frequency
verbal direction to patient wrong or omitted
wrong product
Error type: dispensing error
Patient age: 63
Patient sex: male
Brief summary of incident: Wrong form of inhaler dispensed, prescription stated Qvar autohaler but I dispensed Qvar aerosol. Furthermore the prescription stated 1 puff 3-4 times daily, this is the wrong dose for a steroid inhaler and thus should have been brought to the attention of the prescriber
Name of medication: Qvar 100mcg Autohaler;
Level of harm that could have occurred: 4
The reason you think the potential harm is at the level you have chosen:
There is a likelihood that the patient cannot use a pMDI inhaler effectively and thus had been prescribed an autohaler for this reason and thus his asthma would not sufficiently be controlled. Furthermore this is an overdose, however still not a high dose of inhaled corticosteroid could still potentially have adverse effects and further predispose the patient to oral candidaisis.
Possible cause/contributory factors: Under pressure I did not perform the clinical check of the prescription properly.
Reasons why incident occurred and actions required to prevent reoccurence:
Taking more time, care and having a better checking framework is needed to overcome such errors
Best description of this error/near miss:
wrong medication
wrong frequency
verbal direction to patient wrong or omitted
wrong product