The most common pharmacy errors | What to do if you suspect a medication mistake

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Terry Regan

Director and Head of Medical and Clinical Negligence

Published - 27/09/2023

Pharmaceutical dispensing standards ensure patients get the required medication and the correct dosage. The NHS dispenses roughly 2.7 million items daily, and each time there is a potential for a mistake to occur – which can lead to patients being unable to treat their symptoms or worse. Someone might receive the wrong medicine that doesn’t address their illness or could even contain an ingredient they’re allergic to. It’s essential that you know what to do in the event of a pharmacy error.

In this article, we look at common pharmacy dispensing errors, how to identify a medication error and preventing future mistakes.

Why is safe dispensing important in pharmacies?

Medication errors are the most frequent type of medical error. Although most of these are administration errors in hospitals, it’s still essential that pharmacists work towards limiting mistakes wherever possible. These problems can cause significant patient harm if they don’t get the medicine they need, possibly worsening their condition before they get the correct drug. The pharmacy or pharmacist may be in breach of the law if the patient can prove this was due to negligence from staff. The pharmacy team must take certain precautions to maintain safe dispensing standards.

For example, team members should check that every prescription has the prescriber’s name and signature and the patient’s name and address. This is to make sure the prescription itself is valid and as expected. Pharmacists should use their knowledge of the drug inventory to spot obvious errors, such as if a drug’s quantity is too low or high to threaten patient safety. Finally, pharmacists must also confirm the patient’s identity before giving them any prescription medication; by asking them to verify their full name and address or postcode.

Common types of medication errors in pharmacies

a female pharmacist in a white coat, packing shelves with medication boxes

Medication errors come under the following headings: dispensing, prescribing and administration errors. If your GP or other healthcare professional prescribes you the wrong medicine or dosage, this could be an example of GP negligence rather than pharmacy negligence. Medication administration errors usually occur during hospital treatment, not in the pharmacy. Administration of the wrong intravenous antibiotic, for example. Pharmacy staff are responsible for medicine dispensing errors.

Listed below are several issues that could arise from a medication error:

  • A patient receives someone else’s medication
  • A patient could receive the wrong medication
  • A patient can get the right prescription drug in the wrong dose, limiting its ability to treat their condition or creating adverse side effects.
  • The medication’s labelling might not reflect the medicine within due to a dispensing or manufacturer error.
  • The patient may receive incorrect instructions for medication use

Various factors increase the likelihood of pharmacy medication errors, such as poor communication between faculties, human errors, inadequate pharmacist training or negligence. Workplace pressure, insufficient staffing or distractions can lead to distribution errors, and a pharmacy relying on an outdated computer system could affect the dispensary process and its accuracy.

How can you identify a medication error?

There are several clear signs to be aware of that may signal a medication error, including the following:

  • Rapid changes in a patient’s condition
  • A worsening of the patient’s condition
  • Strange symptoms or unexplained side effects.
  • If you notice signs of an allergic reaction, such as breathing difficulty, swelling or rashes, the patient will need to speak to a medical professional as soon as possible.

In many cases, the error can be easily identifiable by the packaging not matching the prescription or the internal packaging not matching the outer one. Medicine packaging often looks similar, so patients must always double-check the medication they receive from pharmacies. Check the dosage matches the prescription and that the drug inside matches the prescription and the outer packaging.

What to do if you suspect a medication error

Stop taking the medicine if you suspect a medication error or experience an adverse drug event or drug interaction. Speak to your doctor and your pharmacist immediately.

Ensure you keep the original medication packaging and any prescription records; you will need to provide as much detail as possible to your GP, pharmacy and medical negligence solicitor. You may be eligible for medical negligence compensation if the incident caused you harm and you believe it resulted from medical negligence. Contact a specialist lawyer who will advise you on whether or not you have a case. You must also file a report with the hospital, pharmacy, or General Pharmaceutical Council. They will investigate the issue and work to prevent it from reoccurring.

Contact Wake Smith Solicitors to talk about your medical negligence case today!

How can medical errors in pharmacies be prevented?

Roughly 72% of adverse reactions due to medication issues are entirely preventable. Preventing pharmacy dispensing errors could be as simple as pharmacists and patients manually checking each medication. The pharmacy should also ensure that the prescription is valid and includes the proper dosage for each drug. Upgrading the system or even using automation could significantly limit the chances of human error. Checking that you have the right patient is crucial.

Pharmacy errors crucially come down to a lack of proper training, combined with human error. Investment into training and education programs and efforts to improve the working environment for pharmacy staff is imperative.

Frequently Asked Questions

How many medication errors occur each year?

Official estimates suggest over 237 million medication errors yearly in England’s NHS facilities. In community pharmacies, the dispensing error rate is 0.01-3.32% – while this is 0.02-2.7% in hospital pharmacies. Reports don’t always represent all cases, so reporting a medication error is important.

What are the consequences of medication errors?

Medication errors could lead to significant delays in a patient’s recovery and cause symptoms to worsen. Incorrect medications or dosages could cause adverse side effects, allergies or, in the worst case – death.

Which medication is most commonly associated with errors?

NHS data shows that the most common prescribing error involves anticoagulants, antidepressants, opioids, anticonvulsants, and antimicrobials. Common allergens such as penicillin are more associated with medication errors.

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About the author

Terry Regan

Director and Head of Medical and Clinical Negligence

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