Date of incident: 26/02/2013

Error type: dispensing error

Patient age: 32

Patient sex: male

Brief summary of incident: Wrong dose on Rx, clinical check not completed. 10ml prn on Rx, should be 5ml 3-4 times daily

Name of medication: simple linctus;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
The BNF states "preparations such as simple linctus have the advantage of being harmless" although care still has to be taken with all medicines.

Possible cause/contributory factors: My own carelessness.

Reasons why incident occurred and actions required to prevent reoccurence:
Read all of the BNF entry to ensure clinical appropriateness of the Rx. Do a final clinical check, while waiting to counsel patient.

Best description of this error/near miss:
wrong dose strength
wrong frequency