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Institute of Medicine report To Err is Human: Building a Safer Health System highlighted medication error as being widely prevalent, costly and contributing to preventable causes of patient harm. In particular, transitions of care, as patients move between different levels and locations of care, lead to medication error and what has been described as the ‘health care (dis) continuum’. 1 As much as 50% of medication errors and 20% of adverse drug events (ADEs) take place as a result of poor communication during these transitions—admission, transfer and discharge of patients. 2