Date of incident: 10/01/2018

Error type: dispensing error

Patient age: 15

Patient sex: male

Brief summary of incident: In the counselling for Nystatin I forgot to mention to use it after meals and to apply it directly to the lesions in the mouth

Name of medication: Nystatin oral suspension; Daktacort;

Level of harm that could have occurred: 2

The reason you think the potential harm is at the level you have chosen:
Omitting these instructions meant that the patient could incorrectly use the product meaning their condition is not appropriately treated

Possible cause/contributory factors: rushing through the counselling and not carefully reading the PIL

Reasons why incident occurred and actions required to prevent reoccurence:
carefully read the PIL before counselling the patient in order to learn the key points

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