Most safety-critical industries such as airlines, rail and healthcare, build in safeguards to their practices and established procedures. These are often the result of risk assessments that identify the risk and suggest ways to control or mitigate the risk.

It is a fundamental of the Standards for Registered Pharmacies that the pharmacy identifies risks to patient safety, such as risk of dispensing errors, and takes appropriate action to prevent recurrences.

Identifying the risks in the introduction of new services is also a requirement and, as a result of risk assessment, pharmacies have a wide range of standard operating procedures (SOPs), which are regularly reviewed. And yet with all this in place, safety failures, mistakes and human errors can still happen.

It’s easy to say that we wouldn’t have dispensing errors if people just followed SOPs, but it’s not that simple. In the most serious of dispensing errors, there is never just one thing or one person involved. There are often several factors and several safeguards that failed at a particular time and on a particular day.