Date of incident: 13/04/1916

Error type: dispensing error

Patient age: 21

Patient sex: female

Brief summary of incident: Wrong quantity of tablets on label - quantity was in the upper left hand corner of the label and in brackets beside the drug name which indicates that double the quantity actually supplied had been supplied.

Name of medication: Femodette;

Level of harm that could have occurred: 1

The reason you think the potential harm is at the level you have chosen:
This is a quantity labelling error which would cause the patient confusion and most likely to query it, but would not cause physical harm.

Possible cause/contributory factors: I had seen an incorrect example and thought it was the correct way to label for three cycles worth of contraception medicine.

Reasons why incident occurred and actions required to prevent reoccurence:
Reviewed mark sheet, noted that this is a confusing way to label, and added it into checklist.

Best description of this error/near miss:
wrong quantity