School of Pharmacy


Incident Log
Incident Log


Date of incident: 04/03/2013

Error type: dispensing error

Patient age: 56

Patient sex: male

Brief summary of incident: 28 sonata caps was requested by the Rxber. however, due to not reading the BNF carefully, i missed the part where it says it can only be used one daily for up to 14 days only. due to this error, i dispensed 14 caps and make an owing for another 14caps to the patient.

Name of medication: sonata caps;

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
patient might get an overdose if the patient was dispensed with 28 caps

Possible cause/contributory factors: not reading the BNF carefully

Reasons why incident occurred and actions required to prevent reoccurence:
read the BNF carefully

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



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