Date of incident: 20/03/2013

Error type: near miss

Patient age: 7

Patient sex: female

Brief summary of incident: Form of a Schedule 2 CD not on prescription, making the prescription legally invalid, although only one form available in BNF

Name of medication: Concerta XL;

Level of harm that could have occurred: 2

The reason you think the potential harm is at the level you have chosen:
A product with different form might be dispensed to patient. This is unlikely in this case as there is only one form available in BNF.

Possible cause/contributory factors: Carelessness

Reasons why incident occurred and actions required to prevent reoccurence:
Follow SOP in dispensing

Best description of this error/near miss:
wrong medication