Incorrect concentration/strength
Near miss · Jul 8, 2026 · ← Event log
Analyzed — share learnings
Event record
- Patient
- 0–1 · M (age range + gender only)
- Discovered by / prescribed by
- Pharmacist / —
- Stage(s)
- Rx order entry, Preparation / dispensing
- Medication(s)
- Amoxicillin suspension
- Route / associated factors
- oral · Compounded medication
- Degree of harm
- n/a — intercepted before the patient
What happened
Paediatric suspension entered at adult concentration; the mg/kg check at the final verification flagged the dose before release.
Immediate actions
Corrected concentration dispensed; caregiver counselled on dosing syringe.
Causal analysis & action plan✓
Contributing factors
Lack of quality-control systems
Analysis
Default concentration auto-filled from the most-dispensed product rather than the prescribed one.
Action plan
1) Disable concentration auto-fill for paediatric suspensions. 2) Require weight entry before verification for patients under 12.
Share learnings with staff
AIMS requires prompt communication of the event and the actions taken to all pharmacy staff. Record how it was shared (huddle, staff memo, CQI meeting).