Date of incident: 19/04/2013

Error type: dispensing error

Patient age: 7

Patient sex: male

Brief summary of incident: Equasym XL product prescribed twice daily, should only be once daily

Name of medication: Equasym XL 10mg;

Level of harm that could have occurred: 3

The reason you think the potential harm is at the level you have chosen:
This would be an incorrect dosing for this medication and as the patient had the medication before this would lead to the medicine being used ineffectively

Possible cause/contributory factors: Improper understanding of XL preparations, I believed that XL was 12 hour release I have since corrected this error

Reasons why incident occurred and actions required to prevent reoccurence:
More care when reading the BNF and making sure my checking framework is more robust

Best description of this error/near miss:
wrong frequency