7 Worst Pharmacy Errors

3 years ago  •  Add Comment  •  by Donna Bliss

We all make mistakes. So goes the quip, ‘to err is human…’, yet, in some industries, the smallest misstep can have grave consequences. With the never-ending stream of medications and the hours a day spent calculating dosages, the pharmacy profession falls squarely into this category.

Worst Case Scenario

The stakes can be high for pharmacists when it comes to making even a slight miscalculation. This could mean losing their license to practice, paying a hefty fine, facing a high-dollar malpractice suit, or even incurring criminal charges leading to a lengthy prison sentence. For the patient, the physical impact could range from a mild reaction to permanent damage or even death. Errors can also have a lasting emotional and mental impact on the pharmacist, leading to self-doubt, guilt, depression, and in some extreme instances, suicide. While some of these examples are worst case scenarios, the need for accuracy in the pharmacy industry can’t be overstated.

Prevent Defense

Analyzing some potential pharmacy pitfalls may help prevent them from occurring to begin with. And while no list could be so exhaustive as to capture every possible scenario, we’ll look at seven pharmacy errors you might find at the top of the list.

1. Dispensing the Wrong Medication or Dosage

Entering the wrong dosage (1 teaspoon instead of 1 mL), miscalculating a dilution, or inadvertently prescribing the wrong medication all together, any one of these miscalculations could have a devastating effect. Taking time to self-check and then having the prescriptions double-checked by a second set of eyes could stave off a potentially fatal error.

2. Lack of Communication

Patient consultations are an important part of the pharmacy experience. Skipping this step and assuming the patient understands how to administer the medication could lead to easily preventable issues. Taking the time to consult with the patient on dosage, as directed instructions, and frequency also allows the pharmacist another opportunity to ensure that the prescription has been filled correctly.

3. Timidity

Some pharmacists are hesitant to question a doctor or specialist on a prescribed medication if they have concern involving the dosage, potential cross-reaction or drug interactions, or the actual medication itself. A pharmacist stands as the last line of medical authority before the medication makes it into the patients’ hands and yet, some pharmacists don’t realize that they can refuse to prescribe a medication if they have any concerns.

4. Misreading a Handwritten Prescription

Deciphering a handwritten prescription can be tricky, leaving even the most seasoned pharmacist scratching their head, and since most busy pharmacies rely on technicians to decode the script’s chicken scratch, one typo could literally spell trouble.

5. Rookie Mistakes

Rookie mistakes, though unintended can be disastrous.  Whether the new graduate suffers from poor training or they’re struggling under duress caused by peer pressure, expected quotas and metrics, or the stressful demands of a busy pharmacy, any one of these situations could have serious repercussions. Regardless if you are a seasoned vet or a first-year pharmacist, adopting the STAR safety technique is not only a great training tool, but could also help prevent an unintentional error.

6. See Something – Say Something

Most pharmacists develop a personal knowledge of their patient’s medical history beyond just what medications they are on. In most cases, this includes the patient’s past procedures and illnesses. A hesitation to speak up for fear of being too intrusive or possibly upsetting the patient, when you see or hear something that causes concern, could not only lead to possible negative consequences for the patient but could also create a lifetime of undo guilt and regret for the pharmacist.

7. The “Telephone” Game

What was an amusing game when we were children is not so funny where a patient’s safety is concerned! Mishearing or misunderstanding information by taking a prescription over the phone or refilling called-in requests could lead to dangerous errors from important details being lost in translation. By going the extra mile to verify the information, pharmacist and technicians not only provide the patient with peace of mind knowing that their prescription is filled accurately, but they also save themselves from having to notify the Board of Pharmacy of the error.

Final Thoughts

Pharmacists are called on to have a high-level of accuracy in an industry that requires them to administer vaccinations, fill a never-ending stream of prescriptions, meet goals and quotas, address patient’s individual needs, all while working in a high-pressure environment. Though the errors may vary, the fact that the patient is the unwitting victim remains the same. By examining some of the worst pharmacy errors will hopefully raises awareness to help prevent future issues.


  1. Your 10 Worst Pharmacy Mistakes (Drug Topics – April 13, 2018)
  2. Pharmacists Write in: Worst Mistakes, Part 1 (Drug Topics – August 19, 2015)
  3. Eric Cropp Discusses Medical Error That Sent Him to Prison (Pharmacy Times – March 21, 2018)
  4. Safety Focus: STAR (KentuckyOne Health)
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