Case study: Near miss

...Just before handing over the tablets the pharmacist notes from his records that Mrs J is allergic to penicillin...

  • Date: 03 December 2020


Mrs J attends the dental surgery with pain in LL6. An examination and radiograph reveal advanced decay. Her dentist – Dr K – advises extraction and the patient insists that the procedure is done immediately as the pain is “unbearable”. The practice is very busy but an appointment is made for later that day.

The procedure proves difficult. Dr K attempts a forceps extraction but the tooth breaks. He raises a flap and manages to extract the roots. Mrs J is a nervous patient and the procedure is halted numerous times in order for Dr K to offer reassurance.

Post-extraction advice is provided. Since the patient had presented with a facial swelling, amoxicillin is prescribed as an adjunct to the extraction.

Mrs J goes straight from the dental surgery to have the prescription filled. Just before handing over the tablets the pharmacist notes from his records that Mrs J is allergic to penicillin. She returns to the surgery for a new prescription and complains to the practice manager that it was not made clear to her that amoxicillin was in the penicillin family of antibiotics. She is also sure that the allergy is recorded in her records.

The practice manager apologises but a few days later the practice receives a formal letter of complaint. She contacts MDDUS for advice on composing a response.


An MDDUS dental adviser provides feedback on the draft response. In the letter the practice offers an unreserved apology for the error in prescribing amoxicillin to Mrs J. The penicillin allergy is noted in her patient records and the prescription was a clear oversight on the part of Dr K at the end of a very busy and stressful day.

The practice manager reassures Mrs J that the error will be the subject of a significant event analysis (SEA) to improve procedures in order to ensure this does not happen again to any patient. Mrs J is advised that if she still has concerns she is welcome to contact the practice again – or the matter can be referred to the ombudsman.

MDDUS further advises that the practice should routinely require a separate medical history sheet, which is signed and dated by the patient.

Mrs J acknowledges the response and states she has no plans to take the complaint further.


  • Ensure patients routinely complete a medical history sheet before treatment.
  • Practices should make sure that medication alerts are impossible to miss before prescribing.
  • An honest and sincere expression of regret can prevent complaints escalating into legal or regulatory matters.

This page was correct at the time of publication. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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