Example where medicines are prescribed by both the patient’s GP and specialist clinicians, and are administered in a patient’s home.

Risk factors

The following risk factors are present in this example.

Care setting factors

  • Patient has own labelled medicines and only medicines for the household are available, so picking errors may be reduced. However labelled medicines for other household members may be present as may over the counter remedies which are unlabelled which may increase picking errors.
  • No or limited access to medical notes (including specialist care medical records)
  • Patient may have supplies of medicines that have been discontinued or are out of date.
  • More than one organisation prescribing for the individual, resulting in more than one record of medicines.

Personnel factors

  • May have limited medical input and limited access to medical notes (including specialist care medical records) which may increase errors in transcribing.
  • May have little or no clinical pharmacy involvement.
  • Transcribing may be seen as administrative task by registered staff.
  • Registered staff administering medicines, who should be familiar with medicines and indications.

Process factors

  • Patient’s own labelled medicine provides a transcription of the prescription, but this might not reflect any recent changes or have adequate instructions for some medicines (e.g. insulin).
  • Administration undertaken by registered staff who should act as layer of defence if error in transcribing.

Medicine factors

  • May have high risk medicines.
  • May have high risk administration methods.

Risk mitigation

Various countermeasures can be implemented in order to reduce risk.

Controls (processes)

  • A Standard Operating Procedure will be in place to support transcribing.
  • There are no stock drugs within the setting; all are labelled for the individual patient use. This reduces the picking errors.
  • All medicines are labelled for individual use and therefore the label will provide the transcription of the prescription which can be crossed checked with a second source (e.g. current prescription repeat/letter from last specialist appointment which lists medicines they prescribe).
  • Registered staff involved in transcribing will have relevant training and will have a competency assessment annually.
  • Registered staff undertaking the transcribing have contact details of prescribers/specialist teams who have responsibility for prescribing the medicines and are able to contact them for clarification or advice if required.

Controls (responsibilities and accountability)

  • Any transcription will be carried out by a registered nurse and then checked by another trained and competent member of staff.
  • Registered nurses undertake the administration of medicines.
  • Where there are high risk administration methods, a registered nurses will be undertaking the administration, thereby providing a layer of defence if there is a transcription error.


Risk rating

The organisational risk assessment should be used to calculate the risk rating after all the mitigation controls have been put in place.

For example:

Consequences (C)

Likelihood (L)

Risk rating = C x L



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