Around 237 million medication errors occur in England each year 1 . When patients transition between primary and secondary care, they are at significant risk of experiencing unintended changes to their medication 2 .One approach to reduce these errors is the adoption of technology, including electronic prescribing 3 . In September 2017, Bradford Teaching Hospitals NHS Foundation Trust implemented Cerner (https://www.cerner.com/gb/en/about) , an electronic prescribing system, which replaced the traditional paper medical records and chart. Inadvertently, it resulted in a loss of the paper pharmaceutical care plan (PCP), which was used by pharmacy staff as a form of communication to the medical team for drug monitoring and pharmaceutical issues.
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