Date of incident: 04/03/2013

Error type: dispensing error

Patient age: 62

Patient sex: male

Brief summary of incident: Wrong dosing interval stated on label - not those stated by the doctor.

Name of medication: Temgesic 60mcg tablets;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
The dosing interval was stated on label as four to six hours rather than six to eight hours. This could have resulted in overdose or toxicity due to increased levels of the drug in the body.

Possible cause/contributory factors: Time constraints and rushing

Reasons why incident occurred and actions required to prevent reoccurence:
I will ensure that I always check my labels against prescriptions before handing out to a patient.

Best description of this error/near miss:
wrong frequency