Date of incident: 4/3/2013

Error type: dispensing error

Patient age: 45

Patient sex: male

Brief summary of incident: Dispensed 100 Cyclizine instead of 21.

Name of medication: Cyclizine;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
There have been reports of abuse of cyclizine, either oral or intravenous, for its euphoric or hallucinatory effects. The concomitant misuse of Cyclizine Hydrochloride Tablets with large amounts of alcohol is particularly dangerous, since the antiemetic effect of cyclizine may increase the toxicity of alcohol. Patient could also potentially sell the medicine to others who abuse it.

Possible cause/contributory factors: I printed the label first and when I received the only box of cyclizine back from the marker after they were finished I applied the label immediately without checking quantity.

Reasons why incident occurred and actions required to prevent reoccurence:
Double checking quantities.

Best description of this error/near miss:
wrong quantity