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hello and welcome to the elfs medication safety podcast and you know when we have a medication incident an interim port that is made by members staff mrs. reports tamaqua data X reporting system one of the reasons we have this system is though so that we can see themes emerging various areas of the organization and we can identify common errors and ways then that we can fall starts about how to help prevent them from recent incident reports who notices that medication errors are more likely to be made when the dose change section of the description charges you and youll be able to see this on your screen now Alan she says what types of errors are occurring if so a very technical problem is that those changes made to prescription but then the nurse continues to give medication on the old dos so for instance any prescriber changes the prescription from twice a day to once a day but then the nurse continues to give it twice a day now there might be a number of reasons why that happens t