Medication Errors: Pharmacy Technicians on the Front Lines

Posted on 09.05.2012

You walk into a pharmacy to drop off a prescription. Who’s the first person you talk to? A pharmacy technician.

The majority of patients are going to have their first and/or last interaction with a technician. The technician is on the front lines of helping prevent possible medication errors, critical to the patient’s health and safety. There are nearly 4 billion prescriptions for medication filled each year in the United States; close to 1/3 of these are being filled at either a Walgreens or CVS pharmacy. Approximately 1.3 million people are injured annually in the United States from “medication errors.” Whether you are a technician working in a hospital or retail setting there are many key things technicians can do to help prevent these serious and sometimes fatal mistakes from ever happening. But before I even get into that I want you to go here and read Emily’s story.

Two-year-old Emily lost her life to a careless mistake made by a pharmacy technician. The technician who compounded Emily’s chemotherapy IV bag was supposed to use a 0.9% sodium chloride solution; instead she used 23.4% of concentrated sodium chloride. (Solution: meaning the active ingredient is minuet compared to the actual liquid vehicle. Concentrated: meaning the liquid vehicle has been removed thus leaving the active ingredient).  The pharmacist in charge missed the mistake and little Emily, while receiving her last dose of chemotherapy, died from an overdose of sodium chloride that resulted in brain damage. When investigators asked the technician why she used the sodium chloride concentrate the technician replied that she did not know. She claimed that she knew that something was not right but she was not sure.

It is so important to understand the role a pharmacy technician plays when filling a prescription. The pharmacist has a hundred things going on and so they depend on the technician to do their part in making sure things are done correctly. When the patient first drops off the prescription taking 10 seconds to make sure all the correct information is there can prevent so many errors. It is a pharmacy technician’s responsibility to check if the patient’s name is spelled out completely (first and last name). I don’t know how many times I have seen a prescription with just the first letter of the patient’s first name on a prescription; then it was filled for a sibling of the patient. Is the date of birth written large and clear? Can you read what the medication is, directions, quantity, and the doctor’s name? If you answer no to any of these questions, now is the time it can be addressed. Does the patient know what medication is prescribed for them? Does the patient know how they are taking the medication? If there is any question whatsoever, call the doctor and get clarification.

The last opportunity to catch any possible mistakes is when the patient comes back to pick up their prescription. Verifying the name of the patient on the prescription bottle along with the medication name will ensure they are picking up the correct prescription. When the technician has a lot of experience they will also be able to estimate the correct quantity in the bottle and recognize the tablets are in fact the medication listed on the bottle.  Having a second set of eyes look at the prescription can help reduce up to 90% of errors. Prescription drug errors are usually preventable with the implementation of appropriate precautions and procedures. When it comes to patient safety, we can all do our part in reducing these catastrophic events from ever occurring.

Henry J. Kaiser Family Foundation. (2012). State Health Facts. Retrieved September 2012, from SDI Health, L.L.C. Special Data Request: