Previous studies have highlighted slips as a major cause of medication errors (Koren et al., 1986). The drama of patients dying from overdoses of drugs as a result of a misplaced decimal point, or because the names of two drugs were confused, only emphasises the difficulties. However, in this series, we found that slips were much rarer than mistakes, and that medication errors were themselves a rare cause of death as determined at Coroner's Inquest. The "system" in which drugs are used needs to be improved, and that system includes both prescribers and patients. Better education, and more relevant information at the point when doctors prescribe, will help. Some drugs, notably warfarin, lithium, opioids, and potassium chloride, are difficult to use safely, and require especially careful prescribing and monitoring. Nonetheless, however safe systems for prescribing, dispensing, and administering drugs become, patients will continue to die from ADRs. That problem can only be mitigated by a more careful assessment of risks and benefits in prescribing for each patient and every drug, and by the development of safer drugs.
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