The Mechanical Errors

Wrong Drug

The largest category of claims against pharmacists in each edition of the study is "Wrong Drug". This is also the most potentially dangerous error.  As pharmacists, it is difficult for us to believe that we, or a technician, could receive a prescription for one drug, prepare the prescription label correctly, perform a drug review and counsel the patient, and yet have placed the wrong drug into the prescription bottle. Yet, each of us knows this can occur.

The reasons for these errors are varied. The person entering the prescription into the pharmacy’s computer system might select the wrong entry from a list on the screen.  In other cases, a quick code or short cut is entered incorrectly resulting in the wrong product being entered.  

In other cases, technicians simply took the wrong bottle from the shelf and counted out the wrong drug. The pharmacist does not catch the error when checked, or the pharmacist does not check the technician's work. Whatever the reason, the results can be serious.

Wrong Strength of the Drug

The second largest category of claims shown in the Pharmacists Mutual Study is "Wrong Strength." A common example is a pharmacy receives a prescription for digoxin 0.125 mg and fills it with digoxin 0.25 mg. Depending upon the drug prescribed, the results can be dangerous. 

A particular problem in the area of "Wrong Strength" claims are those drugs available in multiple strengths, such as Coumadin® and Synthroid®. There are two main ways in which there errors are made. The first is simply picking up the wrong bottle. The label is correct, but a different strength drug is placed in the bottle. The second way is entering the strength incorrectly into the computer on a new prescription. Pharmacists and technicians need to be alert to these types of errors and develop risk management techniques to prevent these errors.

Wrong Directions

"Wrong Directions" are a significant number of the claims reported in the Pharmacists Mutual Study. These cases involve incorrectly entering the directions into the computer on new prescriptions. In one claim the pharmacist entered a new prescription for birth control tablets into the computer and inadvertently typed "Take two tablets daily." For nine months this patient refilled her birth control prescription every fifteen days, apparently without anyone at the pharmacy noticing.

Often these "Wrong Direction" claims are for children's prescriptions. Technicians and pharmacists need to be particularly alert to directions when a young child is involved. This is particularly true when the child is under school age. The pharmacist should always know the age of the patient when checking a prescription. A good procedure is the "under 6 - over 60 rule." If any patient is under six years of age or over 60 years of age, the pharmacist takes extra care reviewing the directions looking for an error of either the pharmacy or the physician.