Comprehensive strategies—rather than piecemeal efforts—and measures that focus on the entire process of medication rather than on individual mistakes are needed to reduce the incidence of serious errors, said a UK report published last week.

The report, Building a safer NHS for patients. Improving medication safety, reviewed the causes and frequency of medication error and identified models of good practice to improve medication safety.

It found that the causes of errors were complex, involving human lapses and mistakes. Attention was usually focused on the actions of individuals who were considered to be the cause of error, the report warned. However, it found that systems weaknesses that predisposed to human error were important and recommended checks and error …