Learning Event Pdf

Windmill Health Centre

Individual Learning Event Details

No

640

Title

Worng dose Amlodipine

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

Medication Error

What happened?

Phone call from pharmacist querying dose of medication, discussed with on-call GP , patient prescribed both 5mg and 10mg , 10mg hadn't ben taken off repeats

Why did it happen?

Dose change in hospital, eDAN updated but medication not altered also under care of renal team , dose appeared to have been altered from 5mg then back to 10mg on several occasions, different GPs issuing and several admission.