In a suburban community like Larkspur, medication problems often surface in the real-world gaps between care settings:
- Short handoffs between a primary care visit and a pharmacy fill
- Weekend/after-hours coverage where the medication history may not be fully reviewed
- Multiple providers (specialists, urgent care, and routine care) updating meds at different times
- Paperwork delays—discharge instructions, updated prescriptions, and label instructions that don’t match
When the error is tied to that handoff chain, the case often turns on timing: what was ordered, what was actually dispensed, what instructions were given, and when symptoms began.


