QCPP Incident Report

I. Incident Report Details

II. Description of Incident

A medication dispensing error occurred when a patient, Mrs Jane Doe, was given a prescription for metformin 1000 mg instead of the prescribed metformin 500 mg. The error was discovered when Mrs. Doe returned to the pharmacy the following day, reporting unexpected side effects after taking the higher dosage.

III. Individuals Involved

IV. Immediate Actions Taken

1. Apologized to Mrs. Doe for the error.

2. Verified the correct prescription with the original electronic prescription file.

3. Issued the correct medication (metformin 500 mg) to Mrs. Doe.

4. Retrieved the incorrect medication (metformin 1000 mg) from Mrs. Doe.

5. Advised Mrs. Doe on the correct usage of her medication and monitoring for any further side effects.

V. Root Cause Analysis

Identified Causes

• Human Error: The pharmacy technician selected the 1000 mg dosage instead of the 500 mg dosage from the shelf.

• Verification Lapse: The pharmacist did not adequately verify the dosage during the final check before dispensing the medication.

Contributing Factors

• Similar Packaging: The packaging of the 1000 mg and 500 mg metformin is very similar, which may have contributed to the initial selection error.

• High Workload: The pharmacy was experiencing a high volume of customers at the time, leading to increased pressure and reduced attention to detail.

VI. Recommendations and Follow-Up Actions

A. Reinforcement of Double-Check Protocol

Implement a mandatory double-check system where both the pharmacist and pharmacy technician must independently verify the medication and dosage before dispensing.

B. Staff Training

Conduct additional training sessions focused on preventing dispensing errors and the importance of meticulous verification.

C. Medication Storage Review

Reorganize medication storage to ensure clear separation between different dosages, including distinct labeling and color coding to minimize selection errors.

D. Monitoring and Auditing

Introduce periodic audits to monitor adherence to the double-check protocol and identify any recurring issues.

E. Patient Education

Enhance patient education on verifying medications received before leaving the pharmacy.

VII. Sign-Off by Responsible Personnel

VIII. Reporting Personnel

This QCPP Incident Report documents the medication dispensing error, analyzes its causes, and outlines actionable steps to prevent future occurrences, ensuring the pharmacy maintains high standards of patient safety and care.

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