Epidemic of Pharmacy Errors Puts Patients at Risk

There’s a virtual epidemic of medical mistakes taking place in the US today. Attention has focused mainly on those that occur in hospitals, but dangerous errors also happen in pharmacies. Nearly half of Americans take at least one prescription drug daily. According to an article in the Journal of Patient Safety in December 2007, there are 50 million medication errors in pharmacies annually. While individual pharmacy dispensing error rates are low (less than 1% to 4%), the concern about them is valid, as some errors are fatal. A recent survey, Parata Prescription Safety 2008, found one-third of consumers report having experienced a prescription error themselves or knowing someone who has.

Pharmacy errors are one more symptom of a health care system in crisis, observes Larry Sasich, PharmD, MPH, an assistant professor of pharmacy practice at Lake Erie College of Osteopathic Medicine School of Pharmacy in Erie, Pennsylvania. We talked about why pharmacy errors occur, and how you can best prevent them.


In most drugstores today, too few staff members are under too much pressure to fill too many prescriptions in too short a time period, says Dr. Sasich. Though a pharmacist must be on-site at all times when prescriptions are being filled, laws vary about the educational requirements for the person who interacts with the customer. Pharmacies are commonly staffed with more lower-paid technicians than pharmacists, in part because pharmacists now must spend so much more time counting and packaging “pre-fab” drugs and checking insurance coverage than actually compounding medications.

In many pharmacies focused on providing great customer service, an emphasis on speed makes the problem worse. This is a recipe for disaster in nearly any business, especially health care, where a careless mistake can have deadly results. Nonetheless, some pharmacies actually award bonuses to pharmacists based on prescription output, found an investigation by USA Today on the policies and drug errors at large pharmacy chains CVS and Walgreens. The news report described a Massachusetts investigation that uncovered a substantial number of prescription errors.


Common mistakes include misinterpretation of a physician’s written instructions or prescription details. Another is drug name confusion — some names of dissimilar pharmaceutical drugs sound very much alike. We consumers must protect ourselves by being attentive to the medications we are taking. Starting in the doctor’s office, be sure that you are clear on what drug is being prescribed… why it is prescribed… if it is the safest alternative… possible side effects… and dosage instructions, including exactly how much you should take, when and for how long, if it should be taken with or without food, and what to do if you miss a dose.

Next, at the pharmacy…

  • Make certain that the pharmacist understands your doctor’s instructions regarding drugs and dosages. One step in the right direction is that many physician offices now print out computerized prescriptions, which is a big plus for clarity.
  • Review all drugs, including supplements and OTCs, with your doctor and consider bringing the list for your pharmacist to review, as well. This can be helpful in minimizing the possibility of dangerous interactions.
  • Fill all your prescriptions at the same pharmacy. These are usually tracked on their computer, which is programmed to red-flag interactions, at least to the degree that these interactions have been identified and catalogued. If you have to fill a prescription elsewhere, bring the container to your regular pharmacist so the pharmacist can see the label and log the information.
  • When you pick up your prescription, confirm that what appears on the label exactly matches the name of the drug and dosage prescribed by your physician.
  • For ongoing prescriptions, learn to recognize what your medication looks like. If it appears to be different in any way, ask the pharmacist to double-check that it is the correct drug. You can also go to drugdigest.org to look up what your drug is supposed to look like by dose, as well as search for drug information.
  • When possible, call ahead for refills. This puts less time pressure on the pharmacy.
  • Make sure to review the written information that comes with your prescription — usually this includes a complete drug description, including possible side effects and instructions on how to take it. If there is no information provided, ask the pharmacy to print this out for you.

In Dr. Sasich’s opinion, the single most important step any of us can take to remain safe from prescription drug errors is to speak up. Since pharmaceutical technicians may be working behind the counter, fetching and ringing up your prescription, it’s always a good idea to ask to consult with the pharmacist. Before you leave, make sure that you understand everything about your medication and how to take it.