Date of incident: 06/03/2013

Error type: near miss

Patient age: 32

Patient sex: female

Brief summary of incident: Initially told the wrong dosage advice to prescriber for zormorph due to confusion between regular products which are given 3-4 times daily and m/r products which are given every 12 hours

Name of medication: Zormorph 10 mg;

Level of harm that could have occurred: 2

The reason you think the potential harm is at the level you have chosen:
Although it was a higher dose than intended by prescriber, patients can be prescribed very high doses of opioids in appropriate circumstances

Possible cause/contributory factors: Misunderstanding of the following statement: "Dose every 12 hours, dose adjusted according to daily morphine requirement" to mean that the dose is adjusted every 12 hours rather than it is given every 12 hours

Reasons why incident occurred and actions required to prevent reoccurence:
More careful reading of subheadings in the BNF before approaching prescriber

Best description of this error/near miss:
wrong frequency