Infusion pumps on the ward come from three manufacturers

Prescriptions are written in the corridor between other tasks

Patients are moved between wards mid-treatment and the chart lags behind

New nurses are put on drug rounds in their first week

Doctors change doses verbally on the round and the chart is updated later

Verbal orders are accepted over the phone without read-back

Near misses are not reported because the form takes twenty minutes

Errors are discussed as individual mistakes, not as patterns

The same error recurs on the same drug every few months

The electronic chart times out and loses the entry

Double-checking is signed without a second person actually looking

Allergy information is in a different system from the prescribing one

Training on the prescribing system was a one-hour session two years ago

The same look-alike drugs are stored next to each other

Discharge medication lists disagree with the inpatient chart

Alerts in the system are so frequent that they are clicked through

Nobody looks at the error reports together

The drug trolley is shared between two bays

Interruptions during the drug round are constant

Staffing is set by bed count, not by how sick the patients are

Weight-based doses are calculated by hand at the bedside

Nurses are measured on completing the round on time

The ward manager spends most of the shift covering gaps in the rota

Night shift has one nurse for the whole bay

Reporting an error has led to disciplinary action in the past

Agency staff do not know the ward's conventions

Pharmacy reviews charts a day after the first dose was given

Handwritten charts are still used when the system is down, which is often