Medication errors remain a major problem owing to the complexity of the process of prescribing and giving drugs. Experience in the UK can be considered representative of the issues surrounding medication errors that can be found in many national health systems throughout the world. For example, in studies of acute hospitals in the UK, about 10% of the patients on the medical wards experienced an adverse event, half of which were judged to be preventable. Overall, it was estimated in 2001 that the total cost to the National Health Service was about £1billion a year.¹

The presently accepted way of looking at error considers two different aspects. The person-centred approach focuses on the health professional as the cause of the error, highlighting common human failings such as problems of inattention, forgetfulness and carelessness. Despite evidence to the contrary, this approach remains an all too familiar response to errors arising in the National Health Service. The UK Central Council for Nursing, Midwifery and Health Visiting has recorded its concern that nurses who made mistakes …