In suburban communities like Holladay, it’s common for medication to move through multiple steps—primary care visits, urgent care, pharmacy fill, and then follow-up appointments. That creates a real-world risk: the “story” of what was prescribed can get blurred when different providers rely on different medication lists.
We frequently see issues where:
- A clinic visit updates a medication, but the pharmacy receives an older instruction.
- A discharge plan conflicts with what a patient later receives or is told to take.
- An electronic record shows one dosage schedule while the label or the bottle instructions reflect something else.
When mistakes happen across handoffs, the key question becomes: which step failed—and when it failed? That’s why we prioritize assembling the timeline and identifying the specific point of breakdown.


