Date of incident: 20/03/2013

Error type: near miss

Patient age: 67

Patient sex: male

Brief summary of incident: Patient instructed to use two spoonfuls of gel rather than the prescribed one spoonful.

Name of medication: Miconazole 20 mg/g oromucosal gel;

Level of harm that could have occurred: 2

The reason you think the potential harm is at the level you have chosen:
Miconazole overdose may cause vomiting or diarrhoea

Possible cause/contributory factors: Error checking the size of spoon

Reasons why incident occurred and actions required to prevent reoccurence:
Thorough checking of administration instructions

Best description of this error/near miss:
wrong dose strength
verbal direction to patient wrong or omitted