Incident Log
Date of incident: 27/02/2013
Error type: dispensing error
Patient age: N/A
Patient sex: male
Brief summary of incident: Inappropriate item supplied to chiropodist
Name of medication: 5ml Amorolfine hydrochloride nail lacquer; 15
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
I got a written request for stock to be wholesale dealing to a chiropodist. Chiropodists are only allowed POMs which are available on MHRA website. The exempted list for chiropodists does not include hydrocortisone 2.5% cream. They are only allowed hydrocortisone cream 1%. Therefore, it is an inappropriate supply.
Possible cause/contributory factors: Forgot to check on the list in MHRA.
Reasons why incident occurred and actions required to prevent reoccurence:
Always check in MHRA when get written request from chiropodists, midwives and optometrists.
Best description of this error/near miss:
wrong product
Error type: dispensing error
Patient age: N/A
Patient sex: male
Brief summary of incident: Inappropriate item supplied to chiropodist
Name of medication: 5ml Amorolfine hydrochloride nail lacquer; 15
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
I got a written request for stock to be wholesale dealing to a chiropodist. Chiropodists are only allowed POMs which are available on MHRA website. The exempted list for chiropodists does not include hydrocortisone 2.5% cream. They are only allowed hydrocortisone cream 1%. Therefore, it is an inappropriate supply.
Possible cause/contributory factors: Forgot to check on the list in MHRA.
Reasons why incident occurred and actions required to prevent reoccurence:
Always check in MHRA when get written request from chiropodists, midwives and optometrists.
Best description of this error/near miss:
wrong product