7 Dangerous R/X Drug Mistakes


According to research, the two things that cause the most dispensing errors by pharmacists are distractions and multitasking. It is recommended that steps be taken to put barriers up around the pharmacist’s workspace so that they can concentrate, as well as training staff–and having enough staff–to handle all of the customer’s needs.

Also, the workspace should be organized to enhance the flow of the tasks required to fill each prescription to enhance convenience and efficiency. Other considerations are a comfortable, well-lit, climate-controlled environment to work in, with adequate counter space. It is advisable that pharmacists only work with one drug at a time in order to prevent mistakes. In addition to these tips, the following are seven commonly made errors and how to avoid them.

  1. Stored a Medication Improperly

This one is extraordinarily important, considering that most medications are shipped in large quantities. You don’t want to be the one responsible for ruining, for instance, an entire batch of COVID-19 vaccines. Always refer to the literature that comes with the medication, and any drug information references and package inserts. All medications are not created equally, and in fact most are very different, and so require a specific temperature range for stability maintenance.

Another consideration is that your temperature and humidity monitoring systems need to be maintained and in good working order at all times, even when the pharmacy is closed. It is important to assign an employee to check and track any changes in these temperatures in warmers, freezers, and refrigerators multiple times every day.

  1. Dispensed a similar but incorrect drug

A lot of medications sound the same, but are very different, such as buspirone and bupropion. If your pharmacy uses barcode technology, you can lower the risk of dispensing the wrong drug to your patient. Barcode technology should be used at every touchpoint in the dispensation process.

Another way to reduce the risk of dispensing an incorrect medication is to physically separate them on the shelves where they are stored. This goes for meds that sound alike, and ones that look alike as well.

Further, using the method called Tall Man Lettering (TML) can helps well. This is where meds that are similar in name are differentiated by putting some letters in the drug name in uppercase on stock bottles. An example would be the drugs hydroxyzine and hydralazine. In TML, hydralazine would be written hydrALAzine, and hydroxyzine would remain the same.

  1. Forgetting to fully inform a patient about drug interactions and/or serious side effects

It is always best, from the first prescription fill, to build a personal rapport with your patients. This encourages a dialogue and fosters question asking by the client. It is one thing to offer counseling, and another thing to actually do it on a regular basis voluntarily. You should also have computer systems in place to prevent this mistake from happening.

  1. Typos related to abbreviations and zeros

Another error to look out for is mistakes with decimal points, misplaced zeros, and faulty units. It is important to pay careful attention to the package inserts and the writing on the bottles themselves to avoid misinterpretations. One decimal point error could lead to a patient receiving 10 times the amount of medication that they were actually prescribed. Use computer alerts, or, alternatively, you can stock only one strength of a medication. The best way to avoid errors is always to carefully pay attention to zeros, decimal points, and the medication itself.

  1. Communication problems

It is always important to have a pharmacy where all levels of employees feel comfortable questioning one another. This error can be avoided by having policies in place that ensure solid and frequent communication between all employees.

  1. Dispensing the wrong dosage or quantity of medication

Here is another area where using barcode technology is important. Keeping different dosages and strengths of medication on separate shelving is another good way to avoid mistake. A good rule of thumb is to read the label three times before doing anything with the medication.

  1. Data entered incorrectly

It’s a well-known fact that sometimes doctors have terrible handwriting. Be sure that you know that exactly what you are putting from the prescription pad into the computer is the same thing. There are a lot of acronyms, nonstandard abbreviations, illegible writing, and decimals that go into writing some prescriptions, and you’ll never want to get it wrong.

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