1L normal saline with 40 mmol KCL administered instead of Normal Saline 1L. Infusion stopped.

Transcription

1 Incident date Sub category Description Effect on patient 05/01/2012 Wrong dose administered incorrect warfarin dose administered nil 07/01/2012 Wrong drug Cyclzine px'd as 10mg should be 50 mg by Dr. Tinzaparin 40mg prescribed should be oroxaparin. 40mg Amitriphyline 300mg tds prescribed should be 25 50mg on gabapentin not prescribed (should be) nil 09/01/2012 Wrong drug 10/01/2012 Wrong drug 1L normal saline with 40 mmol KCL administered instead of Normal Saline 1L. Infusion stopped. Co amoxiclav 750mg prescrbed pre op. Child weighs 32.7kg dose is 30mg/kg therefore should have been 980mg. Patient reviewed by doctors, bloods taken. No adverse impact evident to patient. 13/01/2012 Wrong drug Aspirin 75mg given in error to wrong patient. 18/01/2012 Wrong dose administered Patient received one litre iv fluid with 40mmol of potassium Observation done.repeat blood done, ecg instead of one litre normal saline. done 24/01/2012 Wrong dose administered Cefalexine 250 mgs but only 500 mgs in box.? whether wrong dose has been given 26/01/2012 Wrong drug wrong jevity feed inplace (jevity promote should have been up but jevity plus was ) 02/02/2012 Wrong drug Oxycodone 5 mg slow release tablet given instead of oxycodone 5 mg immediate release tablet. 04/02/2012 Wrong drug Insilin infusion incorrectly prescribed 07/02/2012 Wrong drug dose of tinzaparin (4500 unit) S/C administered to wrong patient.. 08/02/2012 Wrong drug Carmamazepine 200mg mr given in error instead of tramadol 200mg mr. patient monotored. effect

2 10/02/2012 Wrong drug Novo Rapid given instead of Novamix /02/2012 Wrong dose administered Patient prescribed 2.5 mg of oromorph. 5mg given 14/02/2012 Wrong dose administered Wrong dose of insulin given to patient via syringe pump Did BM and informed medical reg and consultant. IV 10% dextrose comenced 16/02/2012 Wrong drug Sertraline prescribed by mistake. 16/02/2012 Wrong drug Creon transcribed to Creon /02/2012 Wrong drug 1x 25/100mg co careldopa given this morning in error Prescription was for 250 mg co beneldopa 22/02/2012 Wrong drug Given wrong medication due to similarity of name. 09/03/2012 Wrong dose administered thyroxine 75mcg administered instead of Thyroxine 25mcg 11/03/2012 Wrong dose administered PATIENT GIVEN WRONG DOSE ORAMORPH AT AND WAS PRESC 2.5 MG BUT GIVEN 5 MG 15/03/2012 Wrong dose administered Tinzaparin 0.55ml administered instead of 0.5ml. 16/03/2012 Wrong drug Patient given 1 dose of Sando K instead of Phosphate Bloods taken and potassium levels checked. Sandoz. 19/03/2012 Wrong drug Wrong medication prescribed 23/03/2012 Wrong dose administered 100mg of Lamotrigine given instead of 75mg. 27/03/2012 Wrong dose administered pegasys 8 doses, 14 doses administered following the Pt reviewed by consultant prescribed 8. 28/03/2012 Wrong drug Community pharmacy dispensing error (not ECT) 30/03/2012 Wrong drug wrong dose of tinzaparin prescribed 31/03/2012 Wrong drug incorrect prescription written

3 05/04/2012 Wrong drug dispensing error 19/04/2012 Wrong dose administered syringe pump issue 27/04/2012 Wrong dose administered Sando K underdose given 01/05/2012 Wrong dose administered Beriplex 2750units administered instaed of 3000units. 18/05/2012 Wrong drug incorrect dose of tinzaparin 30/05/2012 Wrong drug Long acting Sinemet prescribed instead of short acting. 30/05/2012 Wrong dose administered Clexane dose incorrectly changed 13/06/2012 Wrong drug regular meds incorrectly prescribed pt did not receive 13/06/2012 Wrong drug insulin error 17/06/2012 Wrong drug nausea post tramadol/pca 25/06/2012 Wrong dose administered fentanyl patch 50mcg administered instead of 62mcg 26/06/2012 Wrong dose administered incorrect insulin dose administered 05/07/2012 Wrong drug wrong eye drops prescribed pt did not receicve 13/07/2012 Wrong drug wrong eye drops prescribed pt did not receicve 16/07/2012 Wrong dose administered incorrect insulin dose administered 17/07/2012 Wrong drug Unclear prescription (slow K sando) 29/07/2012 Wrong drug Patient given two doses of Trimethoprim, Patient is allergic Pt observed no ill effects to trimethoprim. 05/08/2012 Wrong drug prescribing error lamivudine instead of lactulose.

4 16/08/2012 Wrong drug In patient prescription post operatively for Diclofenac 100mg b.d. Same administered. 17/08/2012 Wrong drug patient prescribed aspirin and warfarin aspirin crossed off. 19/08/2012 Wrong drug Bumetadine 2.5mg px instead of bendroflumethiazide 2.5 mg. 24/08/2012 Wrong drug Fluticasone administered instead of fludrocortisone. 31/08/2012 Wrong drug patient received water for injections instead of NaCl flush. 31/08/2012 Wrong drug Pt prescribed Morphine Sulphate 10 mg immediate release. Given Oxynorm 10mg immediate release 08/09/2012 Wrong drug Documentation not clear as to what dose of immunoglobulin given. 15/09/2012 Wrong drug Quinine sulphate given instead of Bisulphate 300mg 21/09/2012 Wrong drug Patient was given Zomorph prolonged release instead of Sevredol immediate release. T 23/09/2012 Wrong dose administered Incorrect dose of paracetamol for child based on weight (overdose 1 dose) 25/09/2012 Wrong dose administered incorrect insulin dose administered 26/09/2012 Wrong drug Laxedo given instead of fybogel 06/10/2012 Wrong dose administered Wrong dose of midazolam / diamorphine administered via syring driver 16/10/2012 Wrong drug Dextrose 20mmol kcl administered when it should have been dex saline kcl 20mmols 29/10/2012 Wrong dose administered Patient underdosing antibiotics 11/11/2012 Wrong drug flucloxacillin (contains penicillin) prescribed for penicillin allergic patient pt did not receive. 16/11/2012 Wrong dose administered Clexane 100mg administered instead of 40mg

5 19/11/2012 Wrong dose administered patient was prescribed 2.5 mg to 5 mg midazolam but appears to have been given 7.5mg 20/11/2012 Wrong drug Patient prescribed Apixaban to start post operatively. Patient also on warfarin pre operatively. should be on tinzaparin as warfarin will be recommenced as per consultants instructions. 04/12/2012 Wrong drug patient was dispensed incorrect mediaction Sulfadiazine was prescribed, dispensed Sulfasalazine. Pt did not take Apixaban crossed through. 04/12/2012 Wrong dose administered Patient given incorrect dose of insulin. 34 insulin units given patient glucose monitored instead of 20 insulin units. 13/12/2012 Wrong drug antibiotics requested for patient no infection. NIL. Antibiotics crossed off patient did not receive 22/12/2012 Wrong dose administered Patient administered three additional days of methadone outside of prescription 27/12/2012 Wrong drug Patient prescribed wrong drugs 28/12/2012 Wrong drug Wrong insulin adminstered to the patient. Blood sugar monitored. ill effect 31/12/2012 Wrong drug Insulin precscribed and administerd to a patient who did not need it BM low 20% dextrose administered