Making a mistake

Last updated: Sunday, October 11, 2026

    
                            **We are in the process of updating this scenario in light of new information. You can read more here **

Healthcare professionals can make mistakes because they are people and no-one is perfect. One of the main concerns of the NHS is to make professional people and the environment they work in as safe as possible so that the risks of errors are reduced. But as a pharmacist you have a personal responsibility to reduce your chances of making a mistake as well. For example, you have a duty to be careful, to stay up-to-date, to not work when you are ill, to follow procedures, and to ask for help when you are not sure. These and other practices help reduce risk, but mistakes still occur and professionals must know how to handle them. 

Consider the following example:

It’s your first day on a surgical ward and you are on your own juggling new patients with patients going home and multiple other clinically urgent problems. A busy doctor approaches you and asks for advice about prescribing codeine postoperatively in a mother who is breastfeeding her 4-month-old child. You can't get access to the BNF online so, under pressure, you search for a paper copy of the BNF. You find an old one in the treatment room which advises that codeine may be used, and you inform the doctor accordingly. He asks you to speak to the patient to reassure her. About an hour later you pass the Medicines Information office and drop in to double-check the advice you gave. The MI pharmacist checks their specialist lactation resources and establishes that codeine is no longer recommended in breastfeeding mothers due to the risks posed to the infant.
Have a think about how you might handle this problem. When you’ve had enough thinking time, click forward to the next page.