Date of incident: 3/2/2014

Error type: near miss

Patient age: 55

Patient sex: female

Brief summary of incident: Wrong advice given in counselling on doasge. Labelling issues

Name of medication: Salamol 5mg Steri-neb; Deltacortril e/c 5mg t

Level of harm that could have occurred: 4

The reason you think the potential harm is at the level you have chosen:
The dosage told for Deltacortril e/c 5mg tabs during counselling was an under-dose even though the label had the correct dosage.

Possible cause/contributory factors: Rushing towards the end to make sure that I had covered everything.

Reasons why incident occurred and actions required to prevent reoccurence:
Better time management and review everything before counselling.

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