Errors at the Pharmacy — what is that pill?


Assume you just picked up your prescription for pills at the pharmacy.  The bottle has a label with a drug name, dose and how often to take it.  But, is the pill the right one, the one the doctor had in mind?  Or did somebody make a mistake and put the wrong little green pills in your bottle?  Or perhaps the bottle has the wrong label?  Did you actually get the pills Dr. Jekel prescribed for Mr. Hyde?  Just to keep this in perspective the picture above is of the same medication: losartan;  made in different strengths and by different manufacturers.  Pharmacists do their best to keep the pills straight but they are only human.

To err is human.  But, in most medical situations the goal is an error rate better than 1 in a million.

million (1)

The rate of uncorrected pharmacy errors is much worse:


The estimate of errors varies widely, see the article by James et al.  The 1 error in 33 prescriptions (3%) is an overall estimate of  errors (like the wrong directions on the bottle).  An article by Flynn et all notes “An estimated 51.5 million errors occur during the filling of 3 billion prescriptions each year.”  Death resulting from these errors is unlikely but still is reported.  In everyday terms a local pharmacy will make dispensing errors several times a day.  Large automated pharmacies actually do much better, sometimes in the range of 1 error in 100,000 prescriptions — not too bad but still not good enough.

What can the prescriber do?

  • Always discuss prescribed medications with the patient
  • Tell the patient why each medication is needed
  • Give the patient a complete list of medications and
    indicate which are new, changed, or just continued
  • Send prescriptions electronically

What can the patient do?

  • At the prescriber office or when leaving the hospital
    • Get a complete medication list (or make a list yourself)
    • Record why you take each medication
    • Understand if the medication is scheduled
    • or just taken as-needed for some symptom
    • Record the drug name, dose and how often to take
    • Are you getting enough refills to last until next visit?
    • Ask what the top 3 side effects might be (printed list of a zillion possible side effects is nearly worthless)
  • At the pharmacy, before paying for the medication:
    • Look at the medication bottles and verify
      • Your name
      • The prescribers name
      • Drug name, dose, how often to take
      • Confirm this medication is for your known diagnosis –“this one is for my high blood pressure, right?”
      • Is the quantity and number of refills correct?
    • Ask to look at the pills themselves
      • If this is a refill the pill should look the same as before
        • if not, why not?
    • Did all the prescriptions the doctor prescribe get filled?
    • If you are getting a new medication always allow the pharmacist to talk to you about the medication
    • If the medication is an inhaler ask for instructions and a demonstration
    • If the medication is an injection ask for instructions
    • If the medication is a liquid ask how to measure it
    • If the medication costs $100 a dose or more you have a right to know where it was made and what precautions were taken to avoid counterfeit medications.
  • At home
    • Read the information you were given about the medications
    • ID your pills with an online pill identifier like
    • If you find errors, obviously, contact the pharmacy immediately
    • Report medication errors to the ISMP (Institute for Safe Medication Practices) or if severe to the state pharmacy board.
    • Report pharmacy errors to your prescriber

If you have experienced errors or have other suggestions to avoid errors please leave a comment.

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