Incident Log
Date of incident: 01/03/2013
Error type: dispensing error
Patient age: 33
Patient sex: male
Brief summary of incident: Major labeling error, incorrect warning labels for the formulation dispensed
Name of medication: sporanox;
Level of harm that could have occurred: 3
The reason you think the potential harm is at the level you have chosen:
As incorrect warning labels are present/omitted. No major harm should come about due to this. But there is potential for harm due to omitted warnings.
Possible cause/contributory factors: Stress/time constraints leading to increased pressure, which lead to misreading of the BNF, and therefore the incorrect information was passed onto the patient.
Reasons why incident occurred and actions required to prevent reoccurence:
Always recheck the label before dispensing, use the appendix for the products warning labels opposed to the monograph, to avoid confusion between formulations.
Best description of this error/near miss:
wrong medicine label
Error type: dispensing error
Patient age: 33
Patient sex: male
Brief summary of incident: Major labeling error, incorrect warning labels for the formulation dispensed
Name of medication: sporanox;
Level of harm that could have occurred: 3
The reason you think the potential harm is at the level you have chosen:
As incorrect warning labels are present/omitted. No major harm should come about due to this. But there is potential for harm due to omitted warnings.
Possible cause/contributory factors: Stress/time constraints leading to increased pressure, which lead to misreading of the BNF, and therefore the incorrect information was passed onto the patient.
Reasons why incident occurred and actions required to prevent reoccurence:
Always recheck the label before dispensing, use the appendix for the products warning labels opposed to the monograph, to avoid confusion between formulations.
Best description of this error/near miss:
wrong medicine label