An error must not be looked upon in isolation. The circumstances that people find themselves in at the time will have a bearing on their actions. Some are obvious €“ e.g. familiarity with the pharmacy, tidiness of the dispensary, relationship with the other staff, tiredness, the attitude of the patient, the complexity of the prescription €“ to name just a few. All these things, and many others, have a bearing on our ability, even if we think we are compensating for them. The things we notice affecting us the most are €situational factors€, such as how we feel that day and how we get on with our colleagues and patients.

We are usually aware of local working conditions such as staffing levels, workload and whether the stock is on the shelf. We are usually less aware of things that add pressure but are less easily controlled. These are known as latent factors. Examples include the layout of the dispensary, company targets and the usability of the patient medication record (PMR) system. We are not blind to the risks that surround us, and in normal circumstances we manage these risks effectively. Medication safety incidents occur when the various barriers we have put in place to prevent harm fail. When an incident does occur, it is crucial that the analysis includes a systematic review of all of the contributory factors. It is only by modifying these factors that we can prevent further incidents.