My first 'event'

Made my first mistake since coming back into practice! I dispensed insulin pens against a script for cartridges this week. The patient who brought them back is a regular and was fine about the whole thing, but it didn’t make me feel any better about it.

As part of clinical governance we recorded it as a ‘significant event’ (we are only using a paper based system at the moment, rather than logging these directly with the NPSA).

I also reflected on how I could stop this happening in the future, but the all the pens and cartridges are already on separate shelves in the fridge, so it’s down to me to check, check and recheck again!