INC-1024 — Medication Incident
Medication administration incident – incorrect dosage identified before administration
Under InvestigationModerateMelbourne Healthcare CentrePharmacy
Incident workflow
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Incident overview
- Incident ID
- INC-1024
- Classification
- Medication Incident
- Date & time
- 22 Sep 2026 14:20
- Facility
- Melbourne Healthcare Centre
- Department
- Pharmacy
- Location
- Oncology Day Unit — Medication Room 2
- Reported by
- Nurse Unit Manager, Oncology
- People involved
- 2 clinical staff (de-identified for prototype)
- Severity
- Moderate
- Potential harm
- Moderate — potential adverse medication event
- Confidentiality
- Restricted — Clinical Governance
- Status
- Under Investigation
Description
During preparation of a scheduled chemotherapy dose, the administering nurse identified a dosage discrepancy between the prescription and the dispensed label. The medication was not administered. The prescriber was contacted and the dose was corrected before the patient received treatment.
Immediate action taken
Medication quarantined and returned to pharmacy. Prescriber contacted and corrected order issued. Patient reviewed by treating clinician with no harm identified. Incident escalated to Clinical Governance the same day.
Related records
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