Date of incident: 08/03/2013

Error type: dispensing error

Patient age: 45

Patient sex: male

Brief summary of incident: Major label error - wrong patient name

Name of medication: anafranil sr tablets;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
The patient was already taking an opiod analgesic on prescription. Anafranil sr tablets is a tricyclic antidepressant. These can increase the CNS toxicity of opiod analgesics. Opiod analgesics can also increase the sedative effects of tricyclic antidepressants.

Possible cause/contributory factors: Lack of attention to detail

Reasons why incident occurred and actions required to prevent reoccurence:
Ensure to consult personal checking framework before a medicine is dispensed to patient, to check for labelling errors.

Best description of this error/near miss:
interaction dispensed
wrong patient name on label