The impact on the individual
The vast majority of medication safety errors are made by competent people in error. And yet when a medication safety incident occurs, those who made the error tend to blame themselves and resolve to 'double their efforts'. Inevitably, the person who made the error feels dreadful about it. Trying harder will not prevent slips or lapses, or make us immune to distraction. Punishing the person is also ineffective
Being open
A very small proportion of patients want to pursue a claim for compensation at the outset, but if people don't get an apology, an explanation and assurance, they may feel they have to go to a solicitor.