The theory is sound, but no system in which humans are involved is completely infallible because people make mistakes. It is absolutely the case that on a particular day and in particular circumstances the very best pharmacist is capable of making the very worst mistake.

Humans can make mistakes, and systems that rely on humans being infallible will always be prone to failure.

Instead, our efforts are better directed to creating the best systems and support tools we can to manage the effect of factors that can lead to errors.

Human factors are anything that can affect a person’s performance. Pharmacy teams do not set out to deliberately harm patients, yet through dispensing errors, they may end up doing just that.

Expertise, competence and hard work do not always safeguard against errors and omissions that result in harm. There are times when we can clearly see how a particular action results in an incident or near miss, but often our actions merely breach layers of defence and create unseen conditions of increased risk.