Incident Log
Date of incident: 27/03/2013
Error type: dispensing error
Patient age: 32
Patient sex: male
Brief summary of incident: Directions on the label for the product was written was as " Take THREE or FOUR spoonfuls DAILY" instead of " Take ONE 5ml spoonful THREE or FOUR times s day"
Name of medication: Simple Linctus (200ml);
Level of harm that could have occurred: 3
The reason you think the potential harm is at the level you have chosen:
The size of the spoonful is not indicated for and the patient may be tempted to use other sized spoons to administer the medicine.
Possible cause/contributory factors: Not double and triple checking label before dispensing
Reasons why incident occurred and actions required to prevent reoccurence:
Check label against prescription for directions
Best description of this error/near miss:
wrong dose strength
wrong frequency
Error type: dispensing error
Patient age: 32
Patient sex: male
Brief summary of incident: Directions on the label for the product was written was as " Take THREE or FOUR spoonfuls DAILY" instead of " Take ONE 5ml spoonful THREE or FOUR times s day"
Name of medication: Simple Linctus (200ml);
Level of harm that could have occurred: 3
The reason you think the potential harm is at the level you have chosen:
The size of the spoonful is not indicated for and the patient may be tempted to use other sized spoons to administer the medicine.
Possible cause/contributory factors: Not double and triple checking label before dispensing
Reasons why incident occurred and actions required to prevent reoccurence:
Check label against prescription for directions
Best description of this error/near miss:
wrong dose strength
wrong frequency