To put this into context, consider the following scenarios:

1. Fall from a height
   Harry works as one of the counter staff in his local community pharmacy. The only patients sitting in the shop are waiting for prescriptions which are currently being dispensed. He decides to take the opportunity to restock some shelves and uses a stepladder to reach the higher ones. While Harry is doing this, he leans on a lower shelf which shatters. He falls and bangs his head on a sharp corner and is knocked unconscious. Harry ends up in hospital for several days due to complications and it is over a week before he is able to return to work. The patients were sitting nearby but none of them were hit by falling glass.
2. Technological constraints
   Rebecca is a pharmacy technician who has just started working in the dispensary at the hospital. She dispenses a discharge prescription for the following:
   Metformin 500 mg, one tablet daily for the first week then two daily to continue.
   The computer system in the dispensary means it is difficult to include all of this information on one label. Rebecca decides to dispense it as two separate items; one pack stating one tablet daily, then another pack stating two tablets daily. The first pack, stating one tablet daily, is misplaced when the prescription is undergoing an accuracy check. The patient is given only the second pack so they start on this regimen immediately.
3. Illegible prescription
   It is late afternoon and Leona, who is 17 years old, brings a prescription into the pharmacy. The prescription has got wet in the rain and Rajesh, the pharmacist, cannot read it. He tries to get through to the GP to have it clarified but nobody is answering. As it’s now closing time, he informs Leona that the medicine cannot be dispensed and she goes home without it. Leona has been getting wheezy recently, especially when she exercises, and the prescription was for a newly started salbutamol inhaler.
4. Formulation mismatch
   Rabia is a locum pharmacist on duty at a busy community pharmacy. It is lunchtime and she is the only person in the dispensary. There are several people waiting to be served. Rabia is handed a prescription for prednisolone 5mg enteric coated tablets which she dispenses and checks herself. She does not realise that she has taken prednisolone 5mg off the shelf instead of the enteric coated version that is stored next to it, and she supplies this to the patient
5. Incorrect prescription
   Polly is an 84-year-old lady who is visually impaired. She takes amlodipine, atorvastatin, metformin and aspirin, which is supplied in an MDS. Lydia, a practice pharmacist working at Polly’s general practice, sees Polly in clinic. Lydia decides to add in omeprazole to provide gastric protection, but unintentionally prescribes olanzapine instead. The prescription is sent directly to Polly’s community pharmacy for dispensing, where the addition is not questioned. Polly’s MDS is delivered and she takes her medicines as normal.