Pharmacy prepared Yes Wrong concentration incorrect concentration prepared because of confusion related to the way the Product confusion strengths for the two active ingredients were stated on the The technician didn’t Yes Product preparation LLT Product preparation follow the instructions to error (HLT Product mix the contents of the preparation errors and vial for 5 minutes issues) is more specific reconstitution than LLT Wrong technique in product usage process (HLT Medication errors, product use errors and issues NEC) Respiratory therapist put Yes Product assembly the canister in an inhaler error during the wrong way preparation for use Prescribing errors/issues Scenario Medication LLT Comment error? Drug prescribed in error for Yes Drug prescribing This is a prescribing error. unauthorised use error Off label use should not be coded in addition. Off label use is an intentional act not an error. Prescribed Drug X instead Yes Drug prescribing It is important to be able to of Drug Y because the error identify the confusion as a names sounded alike root cause Drug name alike Prescribed 4 mg/kg Yes Drug dose Even though the error was instead of 0.4 mg/kg. prescribing error detected it was not Prescriber realised intercepted in time immediately and called Wrong dose nurse but nurse had administered already administered the drug.
alike Pharmacy prepared incorrect concentration because of confusion related to the way the strengths for the two active ingredients were stated on the Yes Wrong concentration prepared Product confusion The technician didn’t follow the instructions to mix the contents of the vial for 5 minutes reconstitution Yes Product preparation LLT Product preparation error (HLT Product preparation errors and issues) is more specific than LLT Wrong technique in product usage process (HLT Medication errors, product use errors and issues NEC) Respiratory therapist put the canister in an inhaler the wrong way Yes Product assembly error during preparation for use Prescribing errors/issues Scenario Medication error? LLT Comment Drug prescribed in error for unauthorised use Yes Drug prescribing error This is a prescribing error. Off label use should not be coded in addition. Off label use is an intentional act not an error. Prescribed Drug X instead of Drug Y because the names sounded alike Yes Drug prescribing error Drug name It is important to be able to identify the confusion as a root cause Prescribed 4 mg/kg instead of 0.4 mg/kg. Prescriber realised immediately and called nurse but nurse had already administered the drug. Yes Drug dose prescribing error Wrong dose administered Even though the error was detected it was not intercepted in time
000199_companionptc_r1_01_jun2018.docx