7 ways to cut medication errors in a pharmacy

03-18_Blog-Article 3

Manage your pharmacy systems to reduce mistakes

In brief:

  • A pharmacy filling 250 prescriptions a day averages four mistakes.1
  • Well-designed systems and procedures can reduce errors and ensure that staff find potential errors and prevent them before they impact patients.

Types of errors

A 10-year study found the most common dispensing errors in pharmacies to be dispensing the wrong medications and the wrong dosage.2

Other errors included failing to consult a prescriber with a question or concern, preparation errors, improper substitution, failure to identify overdosing, failure to identify an allergy, and delivering a prescription to the wrong patient.

If your pharmacy fills 2,000 prescriptions a week, statistics show you may have up to two clinically significant errors.3

Even one error that sends a patient to the hospital or causes a death is too many, so take every opportunity to minimize the possibility of an error. Check whether you have taken advantage of these ways to reduce errors:

  1. Organize your workspace. Arrange your physical environment with safety in mind, from storing look-alike medications in separate areas to having an uncluttered, well-lit counter.

  2. Manage workflow. High pressure leads to more mistakes. Medication synchronization, adequate staffing and setting realistic expectations for how quickly staff fill prescriptions take the pressure off. How often staff members take a break isn’t just a staffing issue; it’s a safety issue.

  3. Use technology well. Set alert levels in your pharmacy system to generate attention when it is necessary, but don’t set the alert level so high that alerts are frequent and staff members ignore them. Display names with “tall-man letters” to emphasize the differences, such as hydrOXYzine and hydrALAZINE.4 Give people easy access to online information to check drugs, such as large views of what the proper pills look like.

  4. Flag sound-alike and look-alike medications. Similar names and packaging lead to many errors. Highlight those medications on your shelves and in your computer system so that staff members are paying attention.

  5. Check multiple times. Require checks at each step in the process. Start with the person who receives the prescription verifying the name, date of birth, address and phone number. Be sure you have up-to-date lists of allergies and other medications the patient takes.

  6. Since more than 40% of errors happen when data is being entered into the computer, double check at the time of data entry.2 Then, make the final check at pickup. Ask for the patient’s date of birth and verify that what is inside the bag matches the label. Take time to educate and counsel patients to ensure they understand how to take medications.

  7. Verify oral instructions. Whether you receive a call-in prescription or phone a physician to check illegible or unusual instructions, write down exactly what you are told and read it back for verification.5 Spell out drug names, and say numbers in single digits to avoid confusion, such as between 15 and 50.

  8. Know common mistakes. Download a copy of the Institute for Safe Medication Practice’s “List of Error-Prone Abbreviations, Symbols, and Dose Designations” and train staff members to recognize potential errors.

Make preventing medication errors a priority every day in your pharmacy and at the top of every staff member’s mind. Discuss the errors you catch and plan how to avoid them in the future.


1 “National Observational Study of Prescription Dispensing Accuracy and Safety in 50 Pharmacies,” Elizabeth Allan Flynn et al., Journal of the American Pharmaceutical Association, March/April 2003. LINK
2 “Pharmacy Dispensing Errors: Claims Study Emphasizes Need for Systematic Vigilance,” Jennifer Webb, Drug Topics, March 10, 2015. LINK
3 “Improving Medication Safety in Community Pharmacy: Assessing Risk and Opportunities for Change,” Institute for Safe Medication Practices, 2009. LINK
4 “State Finds Hundreds of Medication Errors Linked to Healthcare Technology,” Bill Siwicki, Healthcare IT News, April 10, 2017. LINK
5 “10 Strategies for Minimizing Dispensing Errors,” Rama P. Nair et al., Pharmacy Times, Jan. 19, 2010. LINK