Blimey starfish - sounds like time for that care agency to review it's practices .
The dosset boxes are filled by the pharmacy and "authorised" by the GP ,so hardly in the same category as giving a tablet that some helpful relative has decanted into a saucer with a note .
I'm saying that as one such helpful relative who is is so tired and in so much pain herself that yes it's quite possible I could make a mistake and give the wrong tablet .
Really that's madness and needs changing .