for his back pain instead of is not a medication the recommended 1 tablet error Miscellaneous medication errors/issues Scenario Medication LLT Comment error? Pharmacist reported that the Yes Circumstance or This is an example of a product label was confusing information potential medication error and that it could result in a capable of leading since the report does not patient receiving the wrong to medication error state that the wrong product dosage form was actually dispensed or administered. The LLT Product label Circumstance or information confusion capable of leading to medication error captures Wrong dosage that the error is a potential form one. The most specific code for the reported type of potential medication error should be selected and the contributing factor, label confusion. Patient drew her insulin out Yes Wrong device The patient uses a of the pen with a syringe used device to prevent an error, because she was confused due to her initial confusion by the numbers on the with the pen markings. The Product design outside of the dosage confusion and the confusion window, and did not want to consequent use of the mistakenly take too much wrong device are both insulin using the pen within a scenario of a medication error, so there is no need to add Intentional device misuse. Patient experienced No Intentional device This is an example of hypoglycaemia after he misuse Intentional misuse: there is used his insulin pen a therapeutic purpose but cartridge as a vial. He there is no mention of a Hypoglycaemia reported that he did so medication error because he had leftover insulin syringes and did not want to waste them.
for his back pain instead of the recommended 1 tablet is not a medication error Miscellaneous medication errors/issues Scenario Medication error? LLT Comment Pharmacist reported that the product label was confusing and that it could result in a patient receiving the wrong dosage form Yes Circumstance or information capable of leading to medication error Product label confusion Wrong dosage form This is an example of a potential medication error since the report does not state that the wrong product was actually dispensed or administered. The LLT Circumstance or information capable of leading to medication error captures that the error is a potential one. The most specific code for the reported type of potential medication error should be selected and the contributing factor, label confusion. Patient drew her insulin out of the pen with a syringe because she was confused by the numbers on the outside of the dosage window, and did not want to mistakenly take too much insulin using the pen Yes Wrong device used Product design confusion The patient uses a device to prevent an error, due to her initial confusion with the pen markings. The confusion and the consequent use of the wrong device are both within a scenario of a medication error, so there is no need to add Intentional device misuse. Patient experienced hypoglycaemia after he used his insulin pen cartridge as a vial. He reported that he did so because he had leftover insulin syringes and did not want to waste them. No Intentional device misuse Hypoglycaemia This is an example of Intentional misuse: there is a therapeutic purpose but there is no mention of a medication error
000199_companionptc_r1_01_jun2018.docx