In a city like Ann Arbor—where residents commonly move between primary care, specialists, and urgent appointments—medication mistakes can slip in at handoffs. Common local scenarios include:
- Same-medication, different instructions after a visit to a new provider or clinic.
- Pharmacy fills for a new prescription that don’t match prior records (especially when a previous medication list wasn’t fully updated).
- Dose changes after labs or imaging are reviewed, but the updated dosing schedule doesn’t reach the pharmacy correctly.
- Weekend or after-hours fills where staff and workflows are managing higher volume and time pressure.
These are not “paperwork problems.” When the wrong dose or wrong instructions are used, the consequences can be immediate—worsening conditions, adverse drug reactions, or delays in appropriate treatment.


