HealthRX.com · Printable dose-error record
Egrifta SV and WR mixing and dose error record
Use this sheet each time you mix Egrifta SV or Egrifta WR, and whenever you are unsure you prepared or injected it correctly. Fill it in by hand and bring it to your prescriber or pharmacist.
Vial and product details
Copy these from the box and vial labels.
Product on the box (SV or WR)Write the name exactly as printed
Strength printed on the vialWrite the strength as printed on the vial
Diluent in the boxWrite the name of the water supplied
Lot number and expiry date
Date the vial was mixed
Name of person who mixed it
Before you mix
Check these against the Instructions for Use in the medication box.
- Confirm the product name on the box matches the vial you hold
- Confirm the diluent is the one named on the label for that product
- Bring the Instructions for Use to every visit
- Note whether the mixing step on the label is roll or swirl
- Check that the vial is not past its expiry date
- Write down any step that is unclear so you can ask about it
Mixing and injection record
Record each mixing and each injection, including any problem you noticed.
| Date | Product | Solution looked clear? | Injection site | Problem or notes |
|---|---|---|---|---|
Questions for your prescriber or pharmacist
- Which Egrifta product is correct for my prescription?
- Is the diluent in my box the one I should use with this vial?
- How should I mix the vial if the solution looks cloudy or has particles?
- What should I do if I think I used the wrong diluent or mixed too much water?
- How long can a mixed vial be kept and when must it be thrown away?
- Should I report a mixing mistake, and to whom?
- Which injection sites should I avoid and how should I rotate them?