Incident Log
Date of incident: 12/02/2013
Error type: dispensing error
Patient age: 43
Patient sex: female
Brief summary of incident: Cyklokapron 500mg tablets presribed. Prescription directions stated "Take two tablets three times daily for four days (for menorrhagia - start when bleeding starts). I forgot to write "for four days" on label. Patient was counselled to start Cyklokapron on day 1 but not about 4 days duration.
Name of medication: Cyklokapron 500mg tablets;
Level of harm that could have occurred: 1
The reason you think the potential harm is at the level you have chosen:
An overdose of cyklokapron can cause stomach upset and potential rash however this would be short term and not life-threatening to the patient.
Possible cause/contributory factors: Ran out of time because other product, co-codamol label took a long time to type out (many warning labels). Did not check over Cyklokapron label properly.
Reasons why incident occurred and actions required to prevent reoccurence:
Need to manage time better in future so not rushed. More thorough checking of label once printed; compare carefully to original prescription
Best description of this error/near miss:
verbal direction to patient wrong or omitted
wrong medicine label
Error type: dispensing error
Patient age: 43
Patient sex: female
Brief summary of incident: Cyklokapron 500mg tablets presribed. Prescription directions stated "Take two tablets three times daily for four days (for menorrhagia - start when bleeding starts). I forgot to write "for four days" on label. Patient was counselled to start Cyklokapron on day 1 but not about 4 days duration.
Name of medication: Cyklokapron 500mg tablets;
Level of harm that could have occurred: 1
The reason you think the potential harm is at the level you have chosen:
An overdose of cyklokapron can cause stomach upset and potential rash however this would be short term and not life-threatening to the patient.
Possible cause/contributory factors: Ran out of time because other product, co-codamol label took a long time to type out (many warning labels). Did not check over Cyklokapron label properly.
Reasons why incident occurred and actions required to prevent reoccurence:
Need to manage time better in future so not rushed. More thorough checking of label once printed; compare carefully to original prescription
Best description of this error/near miss:
verbal direction to patient wrong or omitted
wrong medicine label