Date of incident: 06/03/2013

Error type: near miss

Patient age: N/A

Patient sex: male

Brief summary of incident: hs/nocte interchanged between prescription and label

Name of medication: 28 Mirtazapine 30mg orodispersible tablets;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
Could cause harm to the patient as therapeutic effect could be changed.

Possible cause/contributory factors: Did not do final checking on the label before printing it out.

Reasons why incident occurred and actions required to prevent reoccurence:
Always double check the label before and after printed them off.

Best description of this error/near miss:
wrong frequency
wrong medicine label