Incident Log
Date of incident: 06/03/2013
Error type: dispensing error
Patient age: 29
Patient sex: female
Brief summary of incident: Read the BNF wrong, didnt realise that the product was a modified release product and changed the dosing frequency of the controlled released form to that of an immediate release causing an overdose.
Name of medication: MST Continus;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
The patient would have received an overdose and probably suffered respiratory depression.
Possible cause/contributory factors: Rushing
Reasons why incident occurred and actions required to prevent reoccurence:
Dedicate more time to thoroughly checking the BNF and looking out for once a day and other controlled release preparations.
Best description of this error/near miss:
wrong dose strength
wrong frequency
Error type: dispensing error
Patient age: 29
Patient sex: female
Brief summary of incident: Read the BNF wrong, didnt realise that the product was a modified release product and changed the dosing frequency of the controlled released form to that of an immediate release causing an overdose.
Name of medication: MST Continus;
Level of harm that could have occurred: 5
The reason you think the potential harm is at the level you have chosen:
The patient would have received an overdose and probably suffered respiratory depression.
Possible cause/contributory factors: Rushing
Reasons why incident occurred and actions required to prevent reoccurence:
Dedicate more time to thoroughly checking the BNF and looking out for once a day and other controlled release preparations.
Best description of this error/near miss:
wrong dose strength
wrong frequency