Product confusion errors/issues Scenario Medication LLT Comment error? Patient was dispensed Yes Product packaging Drug Y instead of Drug X confusion due to confusion of product packaging. Drug X and drug dispensed Drug Y had similar looking packaging. Patient purchased over the Yes Product confusion counter (OTC) Drug X 10 g instead of intended Drug X Wrong drug strength 5 g because of selected confusion Patient accidentally took Yes Look pill the wrong drug for a week appearance because the tablets looked identical to his daily Wrong drug vitamin tablets administered Mix-up of 5 mg/ml with 50 Yes Wrong strength It is unclear whether the mg/ml product patient was administered the drug. ‘Strength’ pertains to the product itself; is the ‘dose’ amount of drug the patient receives / should receive. Patient was dispensed Yes Drug name instead of as ‘Drillo’ the pharmacist misheard the name of the drug as Wrong drug when the physician ‘Drillo” dispensed ordered it over the telephone Patient experienced skin Yes Product packaging ulceration applying the confusion wrong topical cream. Error attributed to the creams Wrong drug packaged in the same size administered tube with similar red font and black background. Skin ulceration noted that the product Yes (potential Product packaging Capture the potential is labelled to prepare an IV error) confusion error and the contributing bag for slow infusion over factor
Product confusion errors/issues Scenario Medication error? LLT Comment Patient was dispensed Drug Y instead of Drug X due to confusion of product packaging. Drug X and Drug Y had similar looking packaging. Yes Product packaging confusion drug dispensed Patient purchased over the counter (OTC) Drug X 10 g instead of intended Drug X 5 g because of confusion Yes Product confusion Wrong drug strength selected Patient accidentally took the wrong drug for a week because the tablets looked identical to his daily vitamin tablets Yes Look pill appearance Wrong drug administered Mix-up of 5 mg/ml with 50 mg/ml product Yes Wrong strength It is unclear whether the patient was administered the drug. ‘Strength’ pertains to the product itself; ‘dose’ is the amount of drug the patient receives / should receive. Patient was dispensed ‘Drillo’ instead of as the pharmacist misheard the name of the drug as ‘Drillo” when the physician ordered it over the telephone Yes Drug name Wrong drug dispensed Patient experienced skin ulceration applying the wrong topical cream. Error attributed to the creams packaged in the same size tube with similar red font and black background. Yes Product packaging confusion Wrong drug administered Skin ulceration noted that the product is labelled to prepare an IV bag for slow infusion over Yes (potential error) Product packaging confusion Capture the potential error and the contributing factor
000199_companionptc_r1_01_jun2018.docx