Medication Error

Case Sharing:
Wrong Dose
 Inc ide
nt
▶ IP nurse come to collect medications at ED Pharmacy. Patient’s prescription
contain medications as below:
▶ Paracetamol 250 mg/5 ml Syrup 250 mg , Every 6 hours , 4 Days
▶ Cefuroxime Axetil 125mg/5 ml Suspension 240 mg , Every 8 hours , 7 Days

▶ On 26/05/2022, pharmacist doing ED night shift verified and allocated wrong

dose prescribed by doctor.
 Inc ide
nt
o Doctor wrongly prescribed IV dose for Cefuroxime but intended for tablet dose of
Cefuroxine.
o Pharmacist who did verifying did not realize the mistake and medication
with wrong dose was supplied to patient.
o Next morning on 26/05/2022, pharmacist in charge ED who did
screening and realized wrong dose (Syrup Cefuroxime) was given to
patient.
o Pharmacist in charge called back patient to apologize and arrange patient
to come and collect the correct medication. The wrong dose was not
taken by patient because patient was admitted to ward and given right
dose of IV Cefuroxime in Paediatric Ward.
Sequence of
Events

27.10.21 27.10.21
10:43 15:38

• Received phone • Replied to SN

call from SN to to collect later
collect
medication
ordered by doctor
Sequence of
Events

28.10.21 28.10.21 28.10.21

7:40 7:48 7:55

• Prescriptio • Medic atio

• Prescriptio n filled
n
n verified
allocated
Sequence of
Events

28.10.21 28.10.21
8:05 14:30

• No • SN came and
counterchecking collect medications
was done
because another
staff was taking
breaks
Sequence of
Events
29.10.21 29.10.21 29.10.21
9:38 10:22 14:44
• Received • Called • Informed
called from patient to patient was
ED arrange given right
pharmacist patient dose of IV
regarding come and Cefuroxime
wrong collect the in ward.
medic atio correct Syrup
n being medic atio Cefuroxime
supplied n returned to
pharmacy
unopened
 PATIENT OUTC OME & IMMEDIATE
ACTION
• Incident : Refer to definition of ‘patient safety incident’
NONE
• Near miss: An incident which did not reach the patient.
• No harm incident: One in which an event reached a patient but no
MIL discernable harm resulted
D • Patient: A person who is a recipient of
• healthcare.
Patient outcome: The impact upon a patient which is wholly or partially
MODERATE
the severity and duration of any harm, and any treatment implications,
that result from an incident.
SEVERE
o None – patient outcome is not symptomatic or no symptoms
detected and no treatment is required.
DEAT
o *Mild – patient outcome is symptomatic, symptoms are mild, loss of
H function or harm is minimal or intermediate but short term, and no
CURRENTLY CANNOT or minimal intervention (e.g., extra observation, investigation, review
BE DETERMINED or minor treatment) is required, increase length of stay (up to 72
hours)
o *Moderate – patient outcome is symptomatic, requiring intervention
(e.g., additional operative procedure; additional therapeutic
treatment), an increased length of stay (more than 72 hours to 7
days) .
o *Severe – patient outcome is symptomatic, requiring life-saving
intervention or major surgical/medical intervention, an increased
length of stay (more than 7 days), shortening life expectancy or
forward in the permanent
causing major short term by the term harm or loss of function.
or long
o Death – on balance of probabilities, death was caused or brought
incident.
 Product Description Product # 1 Product # 1(error)
(intended)
16.1 Generic Name (Active Ingredient) Cefuroxime Cefuroxime

16.2 Brand / Product Name

16.3 Dosage Form 125mg/5ml 125mg/5ml

16.4 Dose, frequency, duration, route 150mg tds 240mg tds

Indication of Cefuroxime

▶ Upper & lower resp tract, GUT, skin & soft tissue
infections, gonorrhoea, acute uncomplicated gonococcal
urethritis & cervicitis. Oral susp Early lyme disease &
subsequent prevention of late Lyme disease in adult &
childn >12 yr.
▶ Dose range Childn >2 yr 250 mg bd or 15 mg/kg bd.
Max: 500 mg daily, <2 yr 125 mg bd or 10 mg/kg bd. Max:
250 mg daily.
 Adverse reaction of Cefuroxime

 GI disturbance diarrhoea, nausea & vomiting; pseudomembranous colitis

 Headache
 Eosinophilia
 Transient increases of hepatic enzymes.
 Contributing
Factors

TASK & TECHNOLOGY FACTORS

▶ Wrong Prescription: Dr R endorsed wrong dose of Syrup Cefuroxime (error: using IV dose)
INDIVIDUAL STAFF FACTORS
▶ Lack of knowledge/experience/Skill: PRP SNA is a new PRP (start working March 2022) and it was her first
night shift.
NON COMPLIANCE TO PROTOCOL/SOP/POLICY
▶ PRP SNA did not countercheck with PF senior before dispensing Rx.
Action
Plan
▶ CME on dispensing SOP
▶ Dissemination of lesson learn/dispensing SOP/ Dosing
through Bulletin/
Email