Your Challenge

The Causes

By its very nature, a mistake is not deliberate. But why do they occur? We’ve spent over a decade researching what contributes to medication errors. A complex combination of factors are involved, but here are just a few common reasons.

Paper Based Systems

One would think that in the digital age we would have more electronic systems for medication procedures. Sadly, the majority of activities are still paper based, including issuing prescriptions, ordering stock and medicine administration.


There is little in the way of communication between GPs, nurses and pharmacists. This greatly increases the risk of things going wrong. Discharge notes from hospitals sometimes take too long to reach the surgery or pharmacy. This means that professionals could be working from out-of-date information.

Workflow Processes

The procedures we follow for dispensing prescriptions and administering medication still rely on manual checks. At a very basic level this means that one person administers, and another person has to check it. With these systems there is very little in the way of technology to carry out checks. These processes make things inefficient, as well as prone to errors.

Lack of Information

GPs write prescriptions in the hope that the instructions are followed, but there is no way of knowing what the resident has actually taken. This affects our ability to make informed choices in the interests of the resident. Healthcare professionals are often relying on verbal feedback and assumptions in managing the care of residents.

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