Incident Log
Date of incident: 03/02/2014
Error type: dispensing error
Patient age: 6
Patient sex: female
Brief summary of incident: Ventolin inhale was labelled up as inhale one puff twice daily when required instead of inhale one puff when required
Name of medication: 1;
Level of harm that could have occurred: 4
The reason you think the potential harm is at the level you have chosen:
as the patient may have taken two many puffs and lead to an overdose and therefore side effects would be seen as palpitations, tremor and headache
Possible cause/contributory factors: when labelling i got mixed up between the other inhaler (flixotide) directions
Reasons why incident occurred and actions required to prevent reoccurence:
always double check that the directions on the script are the same as the directions on the label
Best description of this error/near miss:
wrong dose strength
wrong frequency
Error type: dispensing error
Patient age: 6
Patient sex: female
Brief summary of incident: Ventolin inhale was labelled up as inhale one puff twice daily when required instead of inhale one puff when required
Name of medication: 1;
Level of harm that could have occurred: 4
The reason you think the potential harm is at the level you have chosen:
as the patient may have taken two many puffs and lead to an overdose and therefore side effects would be seen as palpitations, tremor and headache
Possible cause/contributory factors: when labelling i got mixed up between the other inhaler (flixotide) directions
Reasons why incident occurred and actions required to prevent reoccurence:
always double check that the directions on the script are the same as the directions on the label
Best description of this error/near miss:
wrong dose strength
wrong frequency