Date of incident: 23/02/15

Error type: dispensing error

Patient age: 7

Patient sex: male

Brief summary of incident: Two liquid based products on script. mixed up the dosing instructions for each when labelling.

Name of medication: galenphol paed linctus; phenergan elixir;

Level of harm that could have occurred: 5

The reason you think the potential harm is at the level you have chosen:
the incorrect dose for phenergan would have resulted in a serious overdose in practice.

Possible cause/contributory factors: unfortunatley was in a rush as had to make up the galenphol form a larger stock bottle. Did not know where to find this and was unsure of the protocols required e.g. measuring out required volume and getting volume checked before proceeding. Wasted time, which resulted in me rushing through labels.

Reasons why incident occurred and actions required to prevent reoccurence:
SOPs in particular for labelling and final checks have been revised.

Best description of this error/near miss:
wrong dose strength
wrong frequency