Patient on anticoagulant Yes Medication monitoring undergoing surgery but it error was not stopped prior to surgery as recommended Failure to suspend in the labelling and patient medication experienced postoperative bleeding Postoperative bleeding Provider prescribed two Yes Labelled drug-drug drugs with known drug interaction medication interaction because he error was unaware of the interaction potential Drug prescribing error Preparation errors/issues Scenario Medication LLT Comment error? Caregiver wasn’t aware to Yes Product assembly Selected term, LLT Product remove the inner cover error during assembly error during from an insulin pen preparation for use preparation for use, is more needle when preparing specific to the reported the pen information than LLT Device use error Product was reconstituted Yes Wrong solution used with the diluent in drug reconstitution Pharmacy compounded Yes Product compounding the wrong strength error product Wrong strength Patient received only one Yes Product preparation component of a error product because the wasn’t Single component of a aware that the two two-component components needed to be product administered mixed together before administration
Patient on anticoagulant undergoing surgery but it was not stopped prior to surgery as recommended in the labelling and patient experienced postoperative bleeding Yes Medication monitoring error Failure to suspend medication Postoperative bleeding Provider prescribed two drugs with known drug interaction because he was unaware of the interaction potential Yes Labelled drug-drug interaction medication error Drug prescribing error Preparation errors/issues Scenario Medication error? LLT Comment Caregiver wasn’t aware to remove the inner cover from an insulin pen needle when preparing the pen Yes Product assembly error during preparation for use Selected term, LLT Product assembly error during preparation for use, is more specific to the reported information than LLT Device use error Product was reconstituted with the diluent Yes Wrong solution used in drug reconstitution Pharmacy compounded the wrong strength product Yes Product compounding error Wrong strength Patient received only one component of a product because the wasn’t aware that the two components needed to be mixed together before administration Yes Product preparation error Single component of a two-component product administered
000199_companionptc_r1_01_jun2018.docx