Medication Errors: How Pharmacy Technicians Can Prevent Them

Medication errors are preventable events that can result in inappropriate medication use or patient harm. They can occur at different stages of the medication-use process, including prescribing, order communication, labeling, dispensing, administration, monitoring, and medication use.

The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) defines a medication error as a preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is under the control of a healthcare professional, patient, or consumer.

Medication errors can range from minor errors that cause no harm to serious errors that can result in significant patient harm or, in severe cases, death.

Pharmacy technicians play an important role in medication safety. Depending on their practice setting and local regulations, technicians may receive prescriptions, enter prescription information, prepare medications, select products, label prescriptions, manage inventory, and assist pharmacists with dispensing activities.

Because many of these tasks are part of the medication-use process, pharmacy technicians must remain alert and follow established safety procedures.

In this article, we will discuss the causes of medication errors, common types of medication errors, and practical ways pharmacy technicians can help prevent them.

What Are Medication Errors?

A medication error is a preventable event that may lead to inappropriate medication use or patient harm.

Medication errors can happen at several points in the medication-use process. For example, an error may occur when a prescription is written, when an order is entered into a computer system, when a medication is selected from the pharmacy shelf, when a label is prepared, or when a medication is administered.

Not every medication error causes harm. However, even an error that does not reach the patient should be taken seriously because it may reveal a weakness in the medication-use system.

For pharmacy technicians, recognizing potential errors and following established safety procedures can help prevent an error from reaching the patient.

Common Causes of Medication Errors

There is rarely a single reason why a medication error occurs. Errors can result from a combination of individual, environmental, communication, and system-related factors.

1. Poor Communication

Poor communication between healthcare professionals can contribute to medication errors.

Incomplete or unclear information about a patient's medication, allergies, dosage, or treatment plan can create opportunities for mistakes.

Pharmacy technicians should communicate clearly with pharmacists and other members of the healthcare team and should promptly refer unclear or questionable prescriptions to the pharmacist.

2. Look-Alike, Sound-Alike Medications

Look-alike, sound-alike (LASA) medications are drugs whose names or appearances can be confused with one another.

For example, two medication names may look or sound similar even though they contain different active ingredients.

Pharmacy staff should pay close attention when selecting medications and should use available alerts, barcode systems, shelf organization, and pharmacist verification procedures to reduce the risk of selection errors.

3. Poor Documentation or Incomplete Information

Incomplete medication records can contribute to errors.

Important information such as allergies, previous medications, medication changes, and relevant patient details may help healthcare professionals make safer decisions.

Accurate documentation and careful review of available information can therefore support medication safety.

4. Incorrect Strength

The same medication may be available in several strengths.

Selecting the wrong strength can result in the patient receiving too much or too little medication.

For example, confusing a 0.5 mg product with a 5 mg product could result in a tenfold difference in dose.

Pharmacy technicians should carefully compare the prescribed strength with the product selected and follow the pharmacy's verification procedures.

5. Incorrect Dosage Form

Medications may be available in different dosage forms, such as tablets, capsules, liquids, creams, injections, immediate-release formulations, and modified-release formulations.

Selecting the wrong formulation can affect how the medication is released or used.

For example, an immediate-release formulation should not automatically be substituted for an extended-release formulation.

Any uncertainty about the dosage form should be referred to the pharmacist before dispensing.

6. Distractions and Interruptions

Pharmacy environments can be busy.

Telephone calls, conversations, prescription requests, patient questions, workload pressure, and interruptions can make it harder to maintain concentration.

Distractions can increase the likelihood of selection, data-entry, labeling, or counting errors.

Creating a work environment that minimizes unnecessary interruptions during high-risk tasks can help improve safety.

7. Illegible or Unclear Prescriptions

Unclear handwriting or ambiguous prescription information can create confusion.

A pharmacy technician should never guess what a prescription means.

If a prescription is unclear, the issue should be referred to the pharmacist or prescriber through the appropriate process.

8. Patient Identification Problems

Patients can sometimes have similar or identical names.

Using appropriate patient identifiers can help prevent one patient's medication from being associated with another patient's profile.

Pharmacy staff should follow the pharmacy's procedures for confirming patient identity before dispensing.

9. Expired or Improperly Stored Medications

Expired medications and products that have not been stored according to their requirements can create medication-safety concerns.

Pharmacy technicians should follow established inventory procedures, check expiration dates where required, and ensure medications are stored appropriately.

Types of Medication Errors

Medication errors can occur in different ways. Common examples include:

• Wrong dose: The patient receives a dose that is too high or too low.

• Wrong medication: A different medication is selected or dispensed.

• Wrong strength: The correct medication is selected but the incorrect strength is used.

• Wrong patient: Medication intended for one patient is associated with or given to another patient.

• Wrong route: A medication is administered through an incorrect route.

• Wrong frequency: A medication is intended to be used at an incorrect frequency.

• Wrong dosage form: The wrong formulation or dosage form is selected.

• Omission: A prescribed medication or dose is unintentionally omitted.

• Wrong time: A medication is administered or taken at an inappropriate time.

• Documentation error: Medication information is entered or recorded incorrectly.

Some errors are intercepted before reaching the patient, while others may reach the patient and cause harm.

How Pharmacy Technicians Can Help Prevent Medication Errors

Medication safety is a shared responsibility. Pharmacy technicians can contribute significantly by following established procedures and recognizing potential problems.

1. Communicate Clearly

Good communication is an important part of medication safety.

If something about a prescription does not make sense, do not guess.

Ask the pharmacist or follow the appropriate clarification process.

A few seconds spent clarifying an unclear order can prevent a much more serious problem.

2. Follow the Five Rights Carefully

The traditional "Five Rights" of medication administration are:

• Right patient

• Right medication

• Right dose

• Right route

• Right time

These principles can reinforce medication-safety practices, although they should not be considered a complete medication-error prevention system.

Pharmacy technicians should also follow the specific checking, verification, and dispensing procedures established by their workplace and jurisdiction.

3. Be Careful With Numbers and Decimal Points

Numbers can have significant consequences in medication use.

For example, writing .5 mg can create ambiguity. Leading zeros should be used for doses less than 1 mg, such as 0.5 mg.

Similarly, trailing zeros should generally be avoided for whole-number doses. For example, 5 mg is safer than 5.0 mg because the latter can potentially be misread as 50 mg.

Always follow accepted medication-safety standards and your workplace procedures when entering or documenting doses.

4. Double-Check Medication Selection

Before preparing a medication, compare the selected product with the prescription carefully.

Pay attention to:

• Medication name

• Strength

• Dosage form

• Quantity

• Directions

• Patient information

Barcode scanning and other technology can provide an additional safety check when available, but technology should complement not replace, careful professional processes.

5. Pay Special Attention to LASA Medications

When medications have similar names or packaging, slow down and verify the product carefully.

Pharmacies may use strategies such as shelf separation, warning labels, computerized alerts, barcode verification, or other safeguards for high-risk or commonly confused medications.

6. Avoid Unsafe Abbreviations

Certain abbreviations can be misunderstood and contribute to medication errors.

Where possible, medication names, directions, and doses should be written clearly and in accordance with accepted medication-safety standards.

Pharmacy technicians should also follow their organization's approved abbreviation policies.

7. Maintain Accurate Documentation

Accurate documentation allows other healthcare professionals to access reliable information.

When entering or updating patient or medication information, carefully verify the information before saving it.

Do not copy information forward without checking that it is still accurate.

8. Reduce Unnecessary Distractions

When performing tasks that require concentration, such as prescription data entry, medication selection, or preparation, minimize unnecessary interruptions where possible.

If you are interrupted during a task, consider restarting the verification process rather than assuming you remember exactly where you stopped.

9. Use Reliable Drug Information Resources

A reliable drug information resource can help pharmacy staff access information about medications, including strengths, dosage forms, interactions, precautions, and other relevant information.

However, pharmacy technicians should work within their scope of practice and refer clinical questions requiring pharmacist judgment to the pharmacist.

10. Never Guess

This may be one of the most important rules in medication safety.

If you are unsure about a medication name, strength, dosage form, patient profile, prescription direction, or any other aspect of an order, stop and ask for clarification.

Guessing can turn uncertainty into a medication error.

What to Do When a Medication Error Is Identified

Medication errors should not simply be ignored, even when the error is caught before reaching the patient.

If you identify a potential or actual medication error:

1. Stop the process if it is safe and appropriate to do so.

2. Immediately notify the pharmacist or appropriate supervisor.

3. Follow your workplace's medication-error reporting procedure.

4. Document the incident accurately according to organizational policy.

5. Do not hide or alter information about the error.

6. Participate in efforts to identify why the error occurred and how similar errors can be prevented.

The goal of medication-error reporting should be to protect patients and improve the medication-use system.

A medication error can reveal a system weakness that needs to be addressed.

Final Thoughts

Medication errors are a serious patient-safety concern, but many errors are preventable.

Pharmacy technicians are an important part of the medication-use process, and their attention to detail can help prevent errors before they reach the patient.

Clear communication, accurate data entry, careful medication selection, proper documentation, patient identification, attention to LASA medications, minimizing distractions, and asking questions when something is unclear can all contribute to safer pharmacy practice.

Most importantly, never be afraid to speak up when something does not look right.

In medication safety, it is always better to pause and ask than to guess and regret.

Every prescription is connected to a real person. Every label matters. Every check matters.

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