Incident Log
Date of incident: 13/02/2013
Error type: dispensing error
Patient age: 50
Patient sex: female
Brief summary of incident: Warning labels missing for erythromycin tablets and inappropriate counselling or advise for simvastatin
Name of medication: Erythromycin 250mg tablets; Simvastatin 10mg
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
Two missing BNF warnings which are labels 5 and 25 for erythromycin tablets. Missing warning labels could lead to wrong way of taking this medicine.As simvastatin and erythromycin should not be taken together, I told the patient to stop simvastatin during 7 days of antibiotic and for a further 7 days which is wrong and it is too long for the patient to stop taking simvastatin.
Possible cause/contributory factors: Mistook wrong product for erythromycin in BNF and hence lead to wrong warning labels.
Reasons why incident occurred and actions required to prevent reoccurence:
Need to check the label carefully and check for the interactions in Stockley.
Best description of this error/near miss:
verbal direction to patient wrong or omitted
wrong medicine label
Error type: dispensing error
Patient age: 50
Patient sex: female
Brief summary of incident: Warning labels missing for erythromycin tablets and inappropriate counselling or advise for simvastatin
Name of medication: Erythromycin 250mg tablets; Simvastatin 10mg
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
Two missing BNF warnings which are labels 5 and 25 for erythromycin tablets. Missing warning labels could lead to wrong way of taking this medicine.As simvastatin and erythromycin should not be taken together, I told the patient to stop simvastatin during 7 days of antibiotic and for a further 7 days which is wrong and it is too long for the patient to stop taking simvastatin.
Possible cause/contributory factors: Mistook wrong product for erythromycin in BNF and hence lead to wrong warning labels.
Reasons why incident occurred and actions required to prevent reoccurence:
Need to check the label carefully and check for the interactions in Stockley.
Best description of this error/near miss:
verbal direction to patient wrong or omitted
wrong medicine label