Incident Log
Date of incident: 04/03/2013
Error type: dispensing error
Patient age: 49
Patient sex: male
Brief summary of incident: Prescription was for Zomorph 10mg capsules (m/r morphine sulfate), one four times daily. Failed to identify that Zomorph was a m/r product which would be taken every 12 hours, rather than immediate release (taken every 4 hours).
Name of medication: Zomorph 10mg Capsules;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
If the patient followed the instructions from product label and counselling, the patient would have overdosed on morphine, which is likely to be fatal to the patient.
Possible cause/contributory factors: Not taking sufficient care when reading BNF and PIL.
Reasons why incident occurred and actions required to prevent reoccurence:
I will be extremely careful checking doses and frequency of medication in the future. I will not feel pressured to rush my clinical checks, as doing so may endanger my patient.
Best description of this error/near miss:
wrong frequency
Error type: dispensing error
Patient age: 49
Patient sex: male
Brief summary of incident: Prescription was for Zomorph 10mg capsules (m/r morphine sulfate), one four times daily. Failed to identify that Zomorph was a m/r product which would be taken every 12 hours, rather than immediate release (taken every 4 hours).
Name of medication: Zomorph 10mg Capsules;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
If the patient followed the instructions from product label and counselling, the patient would have overdosed on morphine, which is likely to be fatal to the patient.
Possible cause/contributory factors: Not taking sufficient care when reading BNF and PIL.
Reasons why incident occurred and actions required to prevent reoccurence:
I will be extremely careful checking doses and frequency of medication in the future. I will not feel pressured to rush my clinical checks, as doing so may endanger my patient.
Best description of this error/near miss:
wrong frequency