9:41
9:41
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Wrong strength caught
at final check
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Severity
Near miss
Category
Dispensing — strength
Store
Camden Road
Shift
Afternoon
Timeline
14:48
Amoxicillin 250mg dispensed against a 500mg label.
15:02
Discrepancy noticed at final check by pharmacist.
15:04
Correct strength prepared. Patient not affected.
Possible contributing factors
Similar packaging
Shelf adjacency
Verbal handover
Busy afternoon
We noticed 3 similar near misses on amoxicillin strengths at Camden this quarter.
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