Beware of Pharmacy Errors

  • Recently, a patient of mine came to me with a question, “Doctor, aren’t my medications supposed to come in green packets, not blue packet?” Well my answer to that question was “Yes,” followed by a “What the heck!” exclamation. After an immediate call to the pharmacist who dispensed the medication, we determined that the pharmacy made an error in filling the prescription and that the patient received a higher dose than prescribed.


    Fortunately, this pharmacy error did not result in death or injury. But other errors have caused harm. You need to be aware that pharmacy errors do happen and that your pharmacist has certain responsibilities.

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    What are the pharmacist’s responsibilities? Each state has its own set of laws governing the pharmacist’s responsibilities. For example, the state of Washington has a standard set of rules for pharmacists that can be found in most states. In general, the pharmacists are responsible for accurately filling prescriptions, labeling prescriptions and dispensing prescriptions. The recent error that my patient encountered obviously violated that basic responsibility.


    Beyond the basic responsibilities, pharmacists are now being expected to uphold a “duty to warn”1 if the patient’s safety is being jeopardized. Case law is now setting this precedent and sending a clear warning to all pharmacists that they are responsible for patient safety too.


    For opioid pain medication prescriptions, a pharmacist should ensure that the patient has a tolerance to opioids before being exposed to high dose opioids intended for opioid tolerant patients. A pharmacist should know the difference between an opioid naïve patient and an opioid tolerant patient because some drugs are contraindicated for opioid naïve patients. An example of an opioid naïve patient is someone who has not received a prescription for opioids in the past 60 days. In a recent case of Dee vs WalMart, the pharmacist dispensed a transdermal fentanyl patch to an opioid naive woman, based on a prescription that was four months old. The courts have decided that there is enough ground for legal action against the pharmacy in this case.


    Other cases are expanding upon the legal duties of a pharmacist to “warn” patients if a drug is not appropriate for them. Drug interactions and past medical histories are all potential reasons for a pharmacist to decide whether or not a medication might pose a safety risk to an individual. If the pharmacist determines that the risk unmistakably outweighs the benefit, then the pharmacist should warn the patient and inform the prescriber.


    In this day and age of big box and mail order pharmacies, the risk for errors made by the pharmacy is growing. And the lawyers are lining up. But I am sure you’d rather not be a victim requiring a lawyer. So what can you do to prevent pharmacy errors from happening to you? When you receive a prescription from your doctor during your appointment, read it over and ask questions. Doctors can make errors in writing a prescription. Once you have your prescription filled at the pharmacy, look it over at the pharmacy. You can even count the number of pills and look at the colors just to make sure you have the right medicine. Check the labels too. If anything looks unusual, ask the pharmacist to review the prescription with you. Had my patient done this, she would not have taken the wrong medicine home with her.


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    Vigilance on the part of doctors, pharmacists and you, the patient, are all necessary to ensure that prescriptions are accurate and safe because errors can happen to anyone.


    1. Truveti, Harit U.  (n.d.).  A Pharmacist's Duty to Warn: Sound Economics, Effective Medicine and Consistent With Drug Regulation Theory.  LEDA at Harvard Law School.  Retrieved from
Published On: May 20, 2012