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. 2000 Nov 11;321(7270):1212–1216. doi: 10.1136/bmj.321.7270.1212

Figure 2.

Figure 2

Therapeutic snakes and ladders. Error is possible during each step of prescribing and giving drugs, and at each check; if checks are omitted, disaster is more likely, but checks later in the process may stop errors that occurred earlier in the process. The last step is irrevocable