Windmill Health Centre<\/p>

Learning Events for 0<\/p>[bws_pdfprint display=\"pdf\"]

No<\/th>	Title<\/th>	Event Date<\/th>	Review Date<\/th>	Ref Date<\/th><\/tr>
639<\/td>	Wrond medicationb<\/a><\/td>	n\/k<\/td>	n\/k<\/td>	n\/k<\/td><\/tr>
640<\/td>	Worng dose Amlodipine<\/a><\/td>	n\/k<\/td>	n\/k<\/td>	n\/k<\/td><\/tr>
136<\/td>	missed anaemia, chest pain\/AF<\/a><\/td>	n\/k<\/td>	n\/k<\/td>	n\/k<\/td><\/tr><\/tbody><\/table> Windmill Health Centre<\/p> Individual Learning Event Details<\/p> No<\/p> 639<\/p> Title<\/p> Wrond medicationb<\/p> Patient Reference<\/p> See extranet<\/p> Event Lead<\/p> <\/p> Event Team<\/p> <\/p> Event Date<\/p> n\/k<\/p> Event Type<\/p> <\/p> What happened?<\/p> 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. \r\nThe error was picked up before the patient collected her prescription.<\/p> Why did it happen?<\/p> When pregabalin is typed into medication tab, the fist option that comes up is gabapentin. \r\nI looked at the dose,100mg and clicked on it without checking the actual name of the drug<\/p> Review Date<\/p> n\/k<\/p> Lessons Learnt<\/p> To be completed after event review<\/p> Reflection Date<\/p> n\/k<\/p> What has changed?<\/p> To be completed after event reflection<\/p> Notes and timeline of action<\/p> <\/p><\/div> Windmill Health Centre<\/p> Individual Learning Event Details<\/p> No<\/p> 640<\/p> Title<\/p> Worng dose Amlodipine<\/p> Patient Reference<\/p> See extranet<\/p> Event Lead<\/p> <\/p> Event Team<\/p> <\/p> Event Date<\/p> n\/k<\/p> Event Type<\/p> <\/p> What happened?<\/p> 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<\/p> Why did it happen?<\/p> 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. <\/p> Review Date<\/p> n\/k<\/p> Lessons Learnt<\/p> To be completed after event review<\/p> Reflection Date<\/p> n\/k<\/p> What has changed?<\/p> To be completed after event reflection<\/p> Notes and timeline of action<\/p> <\/p><\/div> Windmill Health Centre<\/p> Individual Learning Event Details<\/p> No<\/p> 136<\/p> Title<\/p> missed anaemia, chest pain\/AF<\/p> Patient Reference<\/p> See extranet<\/p> Event Lead<\/p> <\/p> Event Team<\/p> <\/p> Event Date<\/p> n\/k<\/p> Event Type<\/p> <\/p> What happened?<\/p> Noted to be anaemic in jun2012, referred for OGD. In interim admitted. no investigation took place, no DNA letter, no follow up. \nACS in 2013, anaemia still not noted. \n2014 c\/o tiredness, blamed on beta blocker. \nfast af in Nov 14, bloods done, noted to have microcytic anaemia and referred lower GI 2ww.<\/p> Why did it happen?<\/p> <\/p> Review Date<\/p> n\/k<\/p> Lessons Learnt<\/p> <\/p> Reflection Date<\/p> n\/k<\/p> What has changed?<\/p> <\/p> Notes and timeline of action<\/p> <\/p><\/div><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":519,"menu_order":62,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2140","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/doctranet.co.uk\/index.php\/wp-json\/wp\/v2\/pages\/2140","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/doctranet.co.uk\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/doctranet.co.uk\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/doctranet.co.uk\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/doctranet.co.uk\/index.php\/wp-json\/wp\/v2\/comments?post=2140"}],"version-history":[{"count":2,"href":"https:\/\/doctranet.co.uk\/index.php\/wp-json\/wp\/v2\/pages\/2140\/revisions"}],"predecessor-version":[{"id":2144,"href":"https:\/\/doctranet.co.uk\/index.php\/wp-json\/wp\/v2\/pages\/2140\/revisions\/2144"}],"up":[{"embeddable":true,"href":"https:\/\/doctranet.co.uk\/index.php\/wp-json\/wp\/v2\/pages\/519"}],"wp:attachment":[{"href":"https:\/\/doctranet.co.uk\/index.php\/wp-json\/wp\/v2\/media?parent=2140"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}