Learning Event Register Full Pdf

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Windmill Health Centre

Learning Events for 0

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No	Title	Event Date	Review Date	Ref Date
639	Wrond medicationb	n/k	n/k	n/k
640	Worng dose Amlodipine	n/k	n/k	n/k
136	missed anaemia, chest pain/AF	n/k	n/k	n/k

Windmill Health Centre

Individual Learning Event Details

639

Title

Wrond medicationb

Patient Reference

See extranet

Event Lead

Event Team

Event Date

n/k

Event Type

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

n/k

Lessons Learnt

To be completed after event review

Reflection Date

n/k

What has changed?

To be completed after event reflection

Notes and timeline of action

Windmill Health Centre

Individual Learning Event Details

640

Title

Worng dose Amlodipine

Patient Reference

See extranet

Event Lead

Event Team

Event Date

n/k

Event Type

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.

Review Date

n/k

Lessons Learnt

To be completed after event review

Reflection Date

n/k

What has changed?

To be completed after event reflection

Notes and timeline of action

Windmill Health Centre

Individual Learning Event Details

136

Title

missed anaemia, chest pain/AF

Patient Reference

See extranet

Event Lead

Event Team

Event Date

n/k

Event Type

What happened?

Noted to be anaemic in jun2012, referred for OGD. In interim admitted. no investigation took place, no DNA letter, no follow up.
ACS in 2013, anaemia still not noted.
2014 c/o tiredness, blamed on beta blocker.
fast af in Nov 14, bloods done, noted to have microcytic anaemia and referred lower GI 2ww.

Why did it happen?

Review Date

n/k

Lessons Learnt

Reflection Date

n/k

What has changed?

Notes and timeline of action