listed next to each other in the catalogue and the names looked very similar Product storage errors/issues Scenario Medication LLT Comment Healthcare facility Yes Improper storage of LLT Poor quality drug reported storing unused product administered should not be reconstituted drug in selected because the syringes past the selected LLT Expired drug Expired drug recommended 30 days, administered is more administered and administering it to specific patients. One of these Lack of drug effect syringes was used by a patient who reported that the drug didn’t work. Vaccine product was Yes Product storage This is a medication error, as stored in the pharmacy at temperature too high the error occurred in the excessive temperatures product use system The pharmacy staff Yes Drug stored in member could not find location drug as it had inadvertently been placed on the wrong shelf Boxes of the drug sent No Manufacturing This storage problem is not from the manufacturer product storage a medication error because were left outside at issue (HLT Product it occurred under excessive temperatures distribution and manufacturing distribution over the weekend when storage issues, SOC and storage activities, prior the wholesaler was closed Product issues). to the product reaching the medication use system Pharmacy delivered the Yes Product storage error This is a medication error, as drug to arrive while the temperature too low the error occurred in the patient was hospitalised. product use system The package was outside at temperatures below freezing for two days (drug should not be frozen). Manufacturer issued a No Manufacturing This storage problem is not recall of certain lots of product storage a medication error because Drug X that were to it occurred under
listed next to each other in the catalogue and the names looked very similar Product storage errors/issues Scenario Medication LLT Comment Healthcare facility reported storing reconstituted drug in syringes past the recommended 30 days, and administering it to patients. One of these syringes was used by a patient who reported that the drug didn’t work. Yes Improper storage of unused product Expired drug administered Lack of drug effect LLT Poor quality drug administered should not be selected because the selected LLT Expired drug administered is more specific Vaccine product was stored in the pharmacy at excessive temperatures Yes Product storage temperature too high This is a medication error, as the error occurred in the product use system The pharmacy staff member could not find drug as it had inadvertently been placed on the wrong shelf Yes Drug stored in location Boxes of the drug sent from the manufacturer were left outside at excessive temperatures over the weekend when the wholesaler was closed No Manufacturing product storage issue (HLT Product distribution and storage issues, SOC Product issues). This storage problem is not a medication error because it occurred under manufacturing distribution and storage activities, prior to the product reaching the medication use system Pharmacy delivered the drug to arrive while the patient was hospitalised. The package was outside at temperatures below freezing for two days (drug should not be frozen). Yes Product storage error temperature too low This is a medication error, as the error occurred in the product use system Manufacturer issued a recall of certain lots of Drug X that were to No Manufacturing product storage This storage problem is not a medication error because it occurred under