Date of incident: 12/03/2013

Error type: dispensing error

Patient age: 54

Patient sex: female

Brief summary of incident: Figures used instead of words within directions on lable. Wrong legal category recorded (POM instead of CD Inv POM recorded). Warning label 3 instead of warning label 2 on product. Wrong coding. Fate of document not recorded.

Name of medication: Dihydrocodeine;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
Directions written in figures rather than words can cause confusion to patient while taking medicine. Warning label 3 instead of warning label 2 can have potential harm to patient if the patient drink alcohol during the treatment. Other dispensing errors are less likely to cause potential harm to the patient, but they may cause confusion if prescription was sent to BSO.

Possible cause/contributory factors: Carelessness and lack of understanding of appropriate labelling.

Reasons why incident occurred and actions required to prevent reoccurence:
Revise NPSA guidance on QOL and check prescription and label more systematically.

Best description of this error/near miss:
wrong frequency
Labelling errors