Learning Event Pdf – Doctranet

Windmill Health Centre

Individual Learning Event Details

[bws_pdfprint display="pdf"]

639

Title

Wrond medicationb

Patient Reference

See practice extranet for full details

Event Lead

See practice extranet for full details

Event Team

Unassigned

Event Date

00/00/0000

Event Type

Near Miss

What happened?

Gabapentin was prescribed instead of pregabalin to a patient. Patient had already been on pregabalin 75mg and the does needed to be increased to 100mg.
The error was picked up before the patient collected her prescription.

Why did it happen?

When pregabalin is typed into medication tab, the fist option that comes up is gabapentin.
I looked at the dose,100mg and clicked on it without checking the actual name of the drug

Review Date

To be arranged

Lessons Learnt

To be completed after event review

Reflection Date

To be arranged

What has changed?

To be completed after event reflection

Notes and timeline of action