MEDICATION ERRORS: Just because we sound alike and look alike doesn’t mean we are alike

Pharmacy TechnicianNo Comments

The most important thing you can do in a pharmacy is make sure you check and double check your work. The next most important thing is to make sure the pharmacist checks and signs off on every prescription filled in the pharmacy—it is law.

I have a personal experience with medication errors. I just went to have a prescription medication filled for my daughter the other day. The medication she was to receive was predisone. She had been prescribed this medication a couple of months earlier, so I knew which drug she was to receive and what I should expect at the pharmacy.

However, when I went to pick up her prescription and as I was reviewing what they had filled, I noticed the drug was in a liquid form instead of the pill form. I told the pharmacist that my daughter had had a pill form a couple of months ago for this same medication, and he said this was a different drug. They had filled her prednisone prescription with prednisolone. It with a different drug that sounded alike and was very similar but was not the same medication.

The pharmacist tried to convince me that prednisolone was what had been prescribed and not prednisone. I asked them to double check to make sure, and after checking he came back and said “I am sorry we missed that! You are right it was for predisone.’’ The pharmacist had signed off on this medication to be dispensed to me, and somewhere in the process an error was made. This error would have affected my daughter’s therapy and would not have been good for her treatment. It was a big error on their part and one that happens far too often. 

My story highlights that it is not only important to check prescriptions as a pharmacy technician—you should also check your own prescriptions when picking them up at a pharmacy. What brought this medication error to my attention was that the drug was dispensed as a liquid instead of pill form. Never hesitate to ask the pharmacy to double check your prescription, especially if you notice anything different.

Pharmacy technicians play a crucial part in preventing medication errors. We are often the first ones to receive a prescription and usually the last person to handle the prescription before it leaves the pharmacy. Be constantly on the lookout for possible sources of medical errors. Adopt safety-oriented work practices to ensure the safety of patients and to avoid adverse patient outcomes.


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