Near miss · Dispensing · Camden Road · Today 15:02
Search incidents, people, stores…
⌘ K
Near missDispensing — strengthResolved · learning loggedWatching · 3 people
Wrong strength caught at final check — amoxicillin 250 vs 500mg
Camden Road Today, 15:02
MP
Reported by Maya Patel Captured via voice (34s)
AI SUMMARY
Regenerate
Amoxicillin 250mg was dispensed against a 500mg label by the dispenser. The pharmacist caught the mismatch at final check, before the patient collected the prescription. The label and bottle have been corrected, the patient received the correct strength, and a brief huddle is recommended given 3 similar near misses this quarter on amoxicillin strengths at Camden.
Timeline
14:48
D. Lin · Dispenser
Picked amoxicillin from shelf and labelled bag for collection.
15:02
M. Patel · Pharmacist
Final check — noticed label / strength mismatch. Halted release.
15:04
M. Patel
Picked correct strength, re-checked against script, dispensed.
15:10
System · Co-pilot
Near-miss report filed via 34s voice capture. Classification auto-suggested.
15:42
D. Lin
Acknowledged report. Re-briefed on strength check.
Discussion · 3 notes
DL
David Lin
2h ago
Owning this — thanks for the heads up Maya. Going to suggest moving the 250s back to the original shelf row.
MP
Maya Patel
1h ago
Agreed. Worth flagging it at the Mon huddle and looping in Soho — they hit the same strength last month.
Contributing factors
Similar packaging
High confidence
Shelf adjacency
High confidence
Verbal handover
Possible
Busy afternoon
Possible
Actions · 1 of 3 done
Re-brief on strength check at picking
D. Lin · due today
Add shelf-divider between strengths
Maya P. · due Fri
Walk-through at Monday huddle
Team · due Mon
Attachments
Co-pilot
Reading your reports · here all shift
PATTERN
Amoxicillin strength confusions are up 40% at Camden this month.
All 4 cases are near misses caught at final check. They share two factors: similar packaging and adjacent shelf placement.
View the 4 casesSuggest a CAPA
Try asking
What patterns are emerging this month?
Show me similar incidents to PS-2418
Suggest CAPA actions for shelf mix-ups
Summarise dispensing errors for the audit
Earlier today
“Summarise this week for the huddle.”
12 reports, 9 near misses. 1 medium (cold-chain) actioned. Two recurring themes: LASA at Soho, strength mix-ups at Camden…