Date of incident: 27/02/2013

Error type: dispensing error

Patient age: 35

Patient sex: female

Brief summary of incident: Wrong quantity of flucloxacillin capsules dispensed. 14 dispensed when should have been 28. "Take one tablet" written as directions when form of medicine was capsules.

Name of medication: Flucloxacillin 250mg;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
An overdose was not dispensed, however this underdose could still cause serious harm to the patient as they would not have sufficient treatment for their infection which could lead to the infection worsening and also, as the patient was not given a full course of the antibiotic, she has been put at risk of developing antibiotic resistance.

Possible cause/contributory factors: Poor checking accuracy under pressure.

Reasons why incident occurred and actions required to prevent reoccurence:
Create a more clear checking framework to allow me to check things accuracy, even when under pressure.

Best description of this error/near miss:
wrong quantity