Incident Log
Date of incident: 03/02/1916
Error type: dispensing error
Patient age: 6
Patient sex: female
Brief summary of incident: Warning label 21 missing on label.
Name of medication: Ibuprofen Oral Suspension Sugar free 100mg/5ml;
Level of harm that could have occurred: 1
The reason you think the potential harm is at the level you have chosen:
As this warning label indicates that the drug should be taken with or just after food or a meal, GI upset could occur, which would be transient and so is minor short term harm.
Possible cause/contributory factors: In my final label checklist, did not include warning labels.
Reasons why incident occurred and actions required to prevent reoccurence:
Amended the checklist and highlighted to ensure vital warning labels are not missed.
Best description of this error/near miss:
wrong medicine label
Error type: dispensing error
Patient age: 6
Patient sex: female
Brief summary of incident: Warning label 21 missing on label.
Name of medication: Ibuprofen Oral Suspension Sugar free 100mg/5ml;
Level of harm that could have occurred: 1
The reason you think the potential harm is at the level you have chosen:
As this warning label indicates that the drug should be taken with or just after food or a meal, GI upset could occur, which would be transient and so is minor short term harm.
Possible cause/contributory factors: In my final label checklist, did not include warning labels.
Reasons why incident occurred and actions required to prevent reoccurence:
Amended the checklist and highlighted to ensure vital warning labels are not missed.
Best description of this error/near miss:
wrong medicine label