Incident Log
Date of incident: 06/03/2013
Error type: near miss
Patient age: 9
Patient sex: female
Brief summary of incident: Equasym XL 10mg capsules were to be prescribed once daily. The prescription stated BD. I failed to realise that this had to be amended by the prescriber and the medicine was dispensed, labelled and councelled to be taken BD.
Name of medication: Equasym XL 10mg Capsules;
Level of harm that could have occurred: 4
The reason you think the potential harm is at the level you have chosen:
Equasym is a schedule 2 controlled drug, and a double dose has been handed out to a child.
Possible cause/contributory factors: I did not recognise that XL formulations are designed for once daily administration.
Reasons why incident occurred and actions required to prevent reoccurence:
Take more care when checking doses in the BNF, and making a personal note that XL formulations are to be administered once daily.
Best description of this error/near miss:
wrong frequency
Error type: near miss
Patient age: 9
Patient sex: female
Brief summary of incident: Equasym XL 10mg capsules were to be prescribed once daily. The prescription stated BD. I failed to realise that this had to be amended by the prescriber and the medicine was dispensed, labelled and councelled to be taken BD.
Name of medication: Equasym XL 10mg Capsules;
Level of harm that could have occurred: 4
The reason you think the potential harm is at the level you have chosen:
Equasym is a schedule 2 controlled drug, and a double dose has been handed out to a child.
Possible cause/contributory factors: I did not recognise that XL formulations are designed for once daily administration.
Reasons why incident occurred and actions required to prevent reoccurence:
Take more care when checking doses in the BNF, and making a personal note that XL formulations are to be administered once daily.
Best description of this error/near miss:
wrong frequency