How to Mistake-Proof the Pharmacy

When working in a Pharmacy as a Pharmacy Technician, care and preparation can help to avoid potentially dangerous and costly medication errors and mistakes. Standardizing intake procedures to always include the patient’s name, address, date of birth and carefully analyzing patient medications, medical history and allergies to medications all under the supervision of a Pharmacist can help maintain a high level of accuracy and a low rate of medication errors. In addition, recognizing medications that sound alike and are spelled alike can also help avoid dangerous mistakes.  Read on to learn more about how to mistake-proof the Pharmacy.

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Statistics on the Problem of Medication Errors in Pharmacies

Every year in the United States, 51.5 million errors occur during the filling of 3 billion prescriptions in Pharmacies nationwide.

In a study conducted in 36 hospitals and skilled nursing facilities in Colorado and Georgia in 2002, 15% of doses (605/3216 doses) were found to be in error with the most common error found to be the wrong time of administration (43%).

The same study found that “omission” of medication doses occurred in 30% of cases with the wrong dose given in 17% of cases.

In another study, over a 7 month period at an academic hospital, hospital pharmacists failed to detect 21% of dispensing errors.

According to another study conducted in 2003 in the US, accuracy rates when dispensing prescriptions at 50 pharmacies in 6 cities had an accuracy rate of 98.3% (77 errors out of 4,481 prescriptions with 5 errors clinically important).

This comports with other studies indicating that the average Pharmacy filling 250 prescriptions per day has an average of 4 prescription errors per day.

Additionally, in a study in the United Kingdom (UK), it was found that for every 10,000 prescriptions filled, on the average, there were 22 “near-miss errors” and 4 actual dispensing errors.

Example of a Lawsuit Filed for Wrongful Death From a Pharmacy Filling Error

It is useful to examine a lawsuit filed for the wrongful death of a patient who was given the wrong medication which eventually led to her death.

In 2013, a lawsuit was filed in Houston, Texas by the son of an 82 year old female patient who was mistakenly given the wrong medication by her Pharmacy which eventually led to her death.

In this particular case, the patient went into her local Walgreens to refill her prescription for 75 mg of hydroxyzine which is an antihistamine that is used to treat itching.

Instead of being given hydroxyzine (also called Vistaril), the patient was actually given 75 mg pills containing hydrochlorothiazide which is a diuretic that increases urinary output and thus drops blood pressure significantly.

After taking the hydrochlorothiazide pill, the patient’s blood pressure dropped dramatically and she was rushed to a local emergency room in acute renal failure.

The patient subsequently ended up on life support and then died (

Commonly Confused Drug Names

In order to help mistake proof the Pharmacy, it is important to review commonly confused drug names such as are included in this condensed version of “ISMP’s List of Confused Drug Names” (this list contains medications that look similar and are spelled alike.)

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Common Reasons for Pharmacy Errors: Mistakes at Intake

At intake of a prescription, the pharmacy technician should have a standardized routine to avoid mistakes such as a prescription for the wrong medication, a prescription for correct medication but at the wrong dosage or a prescription for the wrong patient.

Harmful drug-drug interactions based on other medications that the patient may be taking should also always be considered along with warnings to the patient about any potential harmful or dangerous side effects of any new medication.

Care should always be taken to avoid dispensing any unsafe medications that

continue to be manufactured and inadvertently prescribed

How to Ensure Accuracy at Intake

Be sure to develop a procedure for the intake of prescriptions that includes the following:

  • Carefully confirm the patient’s exact name and date of birth
  • Always write the patient’s date of birth on the hard copy of the prescription
  • Always update any new allergies to medications or new medications into the patient’s profile
  • Always make sure that the prescription is for the correct medication
  • Always make sure that a prescription is for the correct dosage
  • Always make sure that the prescription is for the correct patient
  • Always consider any harmful drug-drug interactions
  • Make sure the patient has been properly warned as to harmful or dangerous side effects of a medication

How to Prevent Medication Errors During the Filling Process?

During the filling process, great care must be taken to select the correct medication stock bottle from the pharmacy shelf.

Many stock bottles look exactly the same and so it is very common to replace a stock bottle in the wrong place on the pharmacy shelf.

Using bar code technology can help to ensure that the right patient is getting the right medication at the right strength and in compliance with the patient’s profile of allergies and medications.


Important ways to Mistake proof the Pharmacy include developing a foolproof technique to ensure accuracy at intake and familiarizing yourself with commonly confused medications in order to catch mistakes early in the filling process. Failure to do so can end up in costly lawsuits, loss of your job and even loss of life.

Medication errors can be reduced by carefully verifying patient identity, allergies to medications and current medical conditions at prescription intake.

During prescription input, great care should be taken to confirm the proper medication, the proper route of administration and the correct dosage.

Finally, when selecting a medication stock bottle from the pharmacy shelf, barcode technology can help ensure that the proper medication is selected and the proper label is applied to the prescription bottle.

Read also our article on How to Screen Prescriptions for Accuracy and Completeness.

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Get information on Pharmacy Technician programs by entering your zip code and request enrollment information.

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