Most people don’t give their medication much thought once it’s prescribed. You trust the doctor who issued it, collect it from the pharmacy, take it as instructed, and trust everything is as it should be.
Despite this, prescribing and monitoring mistakes do happen, with medication errors accounting for 9% of avoidable healthcare costs worldwide.
Understanding how a prescription moves from doctor to patient can help explain where things go wrong and when harm amounts to medical negligence.
Understanding medication errors
A prescription error is classed as any mistake in prescribing, dispensing, administering, or monitoring medication. Between 2015 and 2020, prescription error claims are said to have cost the NHS £35 million (not including legal fees).
Most errors are minor and corrected quickly, but some might not be spotted until the patient becomes unwell. In serious cases, prescription errors can end in long-term injury, hospital admission, or even death.
The 5 steps of a prescription’s journey
More than 113 million prescription items were dispensed across Scotland in 2023/24. Every prescription follows a journey and, at each stage, different healthcare professionals are involved.
Step 1: Prescribing the medication
The prescription journey starts when you speak to your GP or hospital doctor about your symptoms. Based on the details you provide and your medical history (including any medication you’re currently taking), your doctor will decide what medication is best to prescribe.
If a mistake happens at this initial level, it can affect everything that follows—even if the rest of the system works exactly as it should. According to data, 1 in 5 medication errors occur at the prescribing stage.
Step 2: Transcribing and processing the prescription
Once a prescription is written, it’s entered into clinical systems. This stage is often invisible to patients but is a common point where problems can arise.
For example:
- A medication change made in the hospital might not be clearly recorded
- Discharge summaries may be delayed or incomplete
- Electronic records might not be properly updated
Research has shown that electronic order entry systems have significantly reduced transcription and processing errors by removing issues like illegible handwriting. These systems also automatically check for missing information, incorrect doses, patient allergies, and drug interactions.
Step 3: Dispensing the medication
This is the point most patients recognise: collecting medication from a pharmacy.
Pharmacists conduct important safety checks on your prescriptions, including verifying the medication, strength, and quantity. However, dispensing errors can still happen.
A 2025 report found that dispensing error rates vary worldwide — from as low as 0.001% to as high as 11.53% — with the most common error types being:
- Wrong dose or strength
- Look-alike/sound-alike drugs
- Labelling problems
Pharmacists are a vital safety net, but they rely on the information they’ve been given. If something has gone wrong earlier in the process, it may not be obvious at this stage.
Stage 4: Administering the medication
Administration refers to how the medication is given or taken. It’s been reported that more than half (54%) of medication errors occur at this point.
In hospitals, care homes, or community settings, administration might involve a nurse giving medication directly. At home, the patient will likely take it themselves, following the provided instructions.
Administration errors — such as medication being given to the wrong patient or doses given at the wrong time — can have immediate effects on the patient, particularly with high-risk drugs.
Step 5: Monitoring and follow-up
Some medications are prescribed for weeks, months, or even years. Over time, your body and health can change, which means a medication that was once safe may need to be adjusted or stopped altogether.
Monitoring is a key part of safe prescribing. Healthcare professionals are expected to carry out regular checks to ensure the drug remains safe and effective for the patient.
Monitoring failures can include:
- Not arranging blood tests at regular intervals
- Reviewing test results too late or not at all
- Not acting upon abnormal results
- Failing to adjust medication when a patient’s condition changes
- Lack of follow-up for high-risk patients
If your doctor has failed to properly monitor your condition and medication levels, you may have the basis for a legal claim.
What can happen to a patient affected by medication errors?
The effects of medication errors aren’t always immediate or obvious. Patients might start feeling “not quite right” — more tired than usual, dizzy, or nauseous.
In more serious cases, prescription errors can lead to:
- Internal bleeding
- Organ damage
- Severe drops or spikes in blood sugar
- Confusion, falls, or loss of consciousness
- Emergency hospital admissions
When do medication errors become medical negligence?
Medication can cause harm even when it’s prescribed correctly. In healthcare, any injury that occurs as a result of medication is known as an adverse drug event.
Some adverse drug events are unavoidable. An example of this might be a patient who experiences an unexpected or harmful reaction to a drug despite it being prescribed and used appropriately. This reaction could not have been predicted and, therefore, wouldn’t constitute medical negligence.
Other times, adverse drug events are preventable. If mistakes are made in the process — e.g., incorrect prescribing decisions, missed monitoring, or no follow-up — any resulting harm could be considered medical negligence. To make a clinical negligence claim, you must prove the medication error could have reasonably been avoided with proper care.
