A healthcare facility was managing the administration of controlled drugs using a manual, paper-based recording system. Each administration required staff to manually record patient name, date and time, dose, and remaining stock balance. In practice — particularly during busy shifts — staff frequently forgot to complete entries at the time of administration. Entries were missed, times were estimated, and stock calculations were done by hand at month-end. The result was a recurring cycle of calculation errors, discrepancies in controlled drug records, and end-of-month compliance scrutiny. The organisation was spending significant time investigating errors that were entirely preventable — and staff morale suffered under the perception that they were being blamed for a system problem.