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A few months ago, I wrote a blog about human errors comprising one of the leading causes of death in U.S. hospitals and how many healthcare facilities called these events “nevers” (as in, they should never have happened in the first place). I think it’s important to note that it’s not only within the walls of our hospitals or your doctor’s office that such egregious errors are made—sometimes these “never” events occur inside your neighborhood drugstore as well.

As a patient taking a medication, adverse and even life-threatening effects are always a possibility—one that’s exponentially magnified if and when a healthcare professional makes a mistake in the prescribing or dispensation of the drug. When you consider the logistics involved with getting the proper medication into your hands, you start to see the potential for errors.

A doctor might miswrite the name of a drug or even mistakenly switch the dosage instructions between two prescriptions written at the same time. Once there was a time when your local druggist might have personally known you (and your medication history) and watched for any such slip-ups. If the script didn’t make sense, he or she would put in a call to your doctor. Yet in today’s ever-changing world, we’re seeing this level of interaction diminish as many rely on electronically transmitted prescriptions and mail-order pharmacies—while both help to streamline the process, they can also increase the exposure to inaccuracies. In fact, rising incidents of medication errors and related deaths have some healthcare providers and retail pharmacies adopting even newer technologies—including everything from automated tablet counters to medication dispensing robots. Termed the Pharmacy Repackaging Systems Market, it’s an industry that was valued at $997 million in 2015, but expects to reach $1.8 billion by 2024.

Future automation aside, there are currently numerous issues that can now occur behind the pharmacy counter. Instructions can be misinterpreted and pills can be miscounted. Even worse, the wrong medication could be dispensed—doing little for your malady and potentially putting your health at risk. So when do such mistakes move toward malpractice? Usually this is when the patient is harmed through medical negligence, either as a result of certain actions, or failures to act, in filling a prescription.

Some of the more common drug errors that could constitute malpractice include:

  • administering the wrong medication or dosage
  • mislabeling the medication
  • Prescribing a medication that the patient is allergic to
  • prescribing a medication that interacts negatively with other current prescriptions
  • failing to warn the patient of the common side effects of the medication


While understanding the potential for mistakes is half the battle, what can you do as a patient to ensure you get only the benefits of your prescribed medication? Most healthcare professionals recommend you follow these guidelines:

  • Talk to your pharmacist whenever possible.
  • Always double check the drug and dosage before leaving the pharmacy
  • Read the insert that comes with the medication
  • Verify the shape, size, markings and color of the medicine to be correct before taking

Pharmacy mistakes can be rare, but when they occur they can also be serious. Remember that you’re always the final stage in quality control and you should contact your pharmacy and/or doctor if ever in doubt over a given prescription.


  1. Gravatar for Steve Ariens

    Why is not considered malpractice when a Pharmacist refuses to fill a controlled substance for a pt that is known to be dependent on the medication and the only reason that the Pharmacist gives is "I'm not comfortable".. no facts.. just feelings, opinions, biases, phobias. The intentional throwing a pt into cold turkey withdrawal can be as harmful/fatal to the pt as giving the pt the wrong medication. The basic function of a Pharmacist is to make sure that the prescriber is within their scope of practice to prescribe the medication(s), pt's medications do not have a serious (level 1) interaction, the pt is not allergic to any medications, determine medication is within allowable dosing limits and checking the PMP to validate that the pt is not a doc/pharmacy shopper or has demonstrated other potential "red flags" of drug seeking behavior. Shouldn't refusing to fill a pt's medication based on "I'm not comfortable" be a form of malpractice ?

    1. I am sorry to just respond to your comment. It is an interesting issue that you raise. While I am not a pharmacist, I can say that pharmacists do have an obligation to monitor the medications that are given out. I do not believe that they can simply take the position that they are there to fill prescriptions. They do have an obligation to monitor what goes out.

      More to the point, to establish malpractice of any kind, including that of a pharmacist, you have to prove that a reasonably competent pharmacist would not have withheld the prescription. So it is a case by case basis and really depends on the facts of each interaction. So my answer is, it depends. This could be negligence, but not necessarily.

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