Pharmacy Errors

pharmacy error

A pharmacy error could cause many adverse effects to a person or even lead to death. Pharmacy Malpractice happens a lot more than most people think.

The statistics according to Health Affairs,, indicate that pharmacy errors cost upwards of 17 billion dollars.

Sadly, these mistakes result in needless deaths to patients who are trusting their pharmacists and doctors. When a pharmacy gives the wrong dosage or dispenses the wrong medical, the effects range from death of a patient, to minor inconveniences.

In this guide, you will learn what to do if a pharmacy gives you the wrong medication, dosage, or prescription.

Here is a brief outline of what to do if you become a victim of a pharmacy error:

  1. Call your Doctor Right Away
  2. Call the Pharmacy Immediately
  3. Do NOT Give the Mis-Filled Medication Under Any Circumstance
  4. Save the Unused Medication
  5. Save the Bag
  6. Save the Receipt
  7. Save the Empty Bottle
  8. Do NOT Give a Recorded Statement to Anyone Without the Help of a Lawyer

Each pharmacy error is unique in the negligence and side effects caused by the error. A study by the Massachusetts Office of Health and Human Services in 2008 found that the most common causes of errors cited by pharmacists were:

  • Too many telephone calls
  • Overloaded or unusually busy day
  • Too many customers
  • Lack of concentration
  • No one available to double check
  • Staffing shortages
  • Similar drug names
  • No time to counsel the patient
  • Illegible prescription
  • Misinterpreted prescription

A pharmacy error is NOT technically considered as a medical malpractice claim. However, the statute of limitations for a pharmacy error is only 2 years in the state of Florida.

This means you only have 2 years to file a lawsuit to protect your rights if you become a victim of pharmacy negligence. It is governed by Fla. Statute §95.11(4)(a), which sets time limitations for actions based on professional malpractice.

When a pharmacy or pharmacist makes a mistake, the consequences can be fatal. Medication errors are among the most common medical errors, harming at least 1.5 million people every year.

Who is in charge at the pharmacy?

Is the pharmacist really running the pharmacy, or are our medications being dispensed like cheeseburgers?

Unfortunately, corporate greed and profits often cause pharmaceutical mistakes.

Common mistakes made by a pharmacy include:

High Volume – High Stress Pharmacies:

Some pharmacies are run like busy fast food restaurants. They have to process thousands of prescriptions per day.

Unfortunately, with high volume demands and pressure from their employers, most pharmacists have a stressful job which leads to mistakes. Sometimes their mistakes are fatal.

Many pharmacies are national chains and demand a high volume of sales from their pharmacists. Pharmacists that work for national chains are measured by quotas. Some have to fill as many as 50 prescriptions per hour. These type of high volume pharmacies cause a lot of errors.

Some pharmacists are overly stressed by the seemingly ever-increasing prescription volume. These pharmacists need to be aware that workload issues are not a defense against liability for dispensing errors. They are personally responsible for their errors and their employer is equally liable for any damages caused by high volume mistakes.

Sometimes the work environment in a pharmacy is just not a safe place for patients. The work environment for some pharmacies has varying conditions that all combine to make filling a prescription harder than it is supposed to be.

For example, the workload may be just too much for the pharmacy employees to handle. Being a pharmacist is a stressful job when you stop and consider the complexity of their job, as well as the demands of customers, doctors, managers, and co-workers.

Many pharmacies add to the stress by allowing too many interruptions to the work flow. Things like taking phone calls, being asked to help with the cash register, employee morale, and attendance problems can all add to the distractions which lead to pharmacy errors.

Often times the noise level in a pharmacy is a distraction. Consider the phone calls, other employees talking to customers, announcements over the intercom, drive-through speaker, and trying to concentrate on what you’re doing all at the same time.

Sound Alike Errors:

Many medications have similar names that sound alike. Pharmacists make mistakes due to the similar sound of medicines that, usually, have totally different uses. When the wrong medication is given, problems occur.

For example, we handled a case in which the doctor ordered an oral solution of Lidocane, but the pharmacist delivered Lindane. Lidocane was prescribed to help the woman who had an oral yeast infection be able to tolerate the yeast pills with Lidocane which numbs the mouth, and allows the bad tasting yeast to stay in the mouth longer.

Unfortunately, the pharmacist gave our client a bottle of Lindane, which is a lice poison, which should only be used on the skin, and never taken in the mouth.  Our client followed her doctor’s instructions and when she put the Lindane in her mouth, it burned terribly and tasted horrible.

So she called the pharmacy to tell them about the bad taste and burning feeling.  The pharmacist told her “all medicine tastes bad, and you have to hold it in your mouth for a long time to get the therapeutic effect.”

Unfortunately, our client followed the pharmacist’s instructions, took a big mouthful of the Lindane, held it in her mouth as long as she could, until the pain was unbearable.  She spit out the Lindane and her mouth was bleeding.  She then developed sores on the inside of her mouth for the rest of her life.

The doctors put her on steroids for years to reduce the inflammation in her mouth. This case went all the way to a jury trial.

The Food and Drug Administration tracks reports of medication errors caused by drug name confusion.   The FDA cites the inadvertent administration of Methadone rather than the intended Metadate ER (methylphenidate) for the treatment of attention-deficit/hyperactivity disorder.

Some other examples of documented confusion from the FDA include:

  • Serzone (nefazodone) and Seroquel (quetiapine);
  • Lamictal (lamotrigine) and Lamisil (terbinafine);
  • Taxotere (docetaxel) and Taxol (paclitaxel);
  • Zantac (ranitidine), Zyrtec (cetirizine), and Zyprexa (olanzapine);
  • Celebrex (celecoxib) and Celexa (citalopram);
  • In 1994, the FDA changed a drug name after it was approved when the thyroid medicine Levoxine (levothyroxine) was being confused with the heart medicine Lanoxin (digoxin). Meadows M. Strategies to reduce medication errors. FDA Consumer. 2003;37(3).  Accessed October 1, 2008.

Improper Compounding Errors:

In some pharmacies, the pharmacists literally make the medicine as prescribed by the doctor.  The pharmacist literally compounds various chemicals and medicines to make just what the doctor ordered.

We handle cases where the pharmacist made a mistake and caused the medicine they compounded to be 3,000 times the strength of what it was supposed to be.  This caused a terrible reaction to the patient causing multiple stays in the hospital and hundreds of thousands of dollars of treatment to restore our client’s health.  This mistake could have easily been avoided if the pharmacist had been more careful.

In fact, the large chain pharmacy fired the pharmacist after realizing the mistake.  A math miscalculation can happen easily and the pharmacist needs to pay special attention to the desired dosage.

Improper Drug Strength, Dosage Errors:

Another common pharmacy error is that when the pharmacist fills the prescription, they do so with the wrong strength dosage.  Either too strong or too weak.  For example, and doctor may order 0.25mg and the pharmacists dispenses 25mg, which is 100 times more than the doctor ordered.

This is another risk that often leads to hospitalization and health risks.  On a low level, a medication error may not cause a problem for a patient, but high level errors can result in severe complications for the patient, including death.

These types of medication errors are difficult to detect because we rely upon the pharmacist to do their job properly.  Sadly, how is someone to know if the prescription was filled properly? If you have concerns about the concentration of your medication, please consult your doctor and ask them to confirm that the strength of your medicine is in the amount the doctor has prescribed for you.

Mislabeling Instruction Errors:

This is when the proper medication is given, but the instructions are wrong.  This often causes inadequate instructions to be given to the patient and they inadvertently take the medication in a way that harms them.

Mistakes include frequency of taking the medication, too often or not often enough, how much to take, too much or too little, what not to take with the medication to prevent side effects, or the side effects that may be experienced from the medication.

Contraindicated Errors:

Pharmacies occasionally fill a prescription that is “contraindicated,” when a pharmacist has been filling a patient’s prescription for a while they should know what two different medications cannot be taken together.  For example, high blood pressure medication cannot be taken with angiotensin medications.

This can happen when a patient sees two different doctors, one doctor for one condition, and another doctor for a different condition and one of the doctors did not know that the patient was taking a certain kind of medicine which cannot be taken with the medication that the doctor just prescribed.

If a pharmacist were to fill both prescriptions without warning the patient or calling the doctor, then this is an unfortunate pharmacy error that they should catch.  Isotretinoin, a drug used to treat acne, is absolutely contraindicated in pregnancy due to the risk of birth defects.  A person who takes Warfarin to thin the blood should not take aspirin.

These are common knowledge to any pharmacist.  And any pharmacist dispensing any of these types of medications should warn the patient about these risks and side effects.

Dispensing drugs that are beyond the expiration date:

Some pharmacies have old stock, and rather than destroy the medication, they dispense it.  This often causes the patient to receive a dosage that has become weaker over time due to its aging.

Substituting Generic Drugs Without Informing the Patient:

Dispensing a generic drug, which is substituted for a brand name drug without informing the patient of the substitution, is a common occurrence.   This usually does not cause adverse side effects to the patient, but occasionally it does.

This is often a profit scheme by some pharmacies.  If you have questions about the efficacy of a generic drug, you should ask your physician.

Improper Refilling Errors:

Refilling a prescription without proper authorization from the prescribing physician.

Failing to Counsel the Patient:

This is governed by Florida Administrative Code section 64B16-27.820 Patient Counseling which requires that the pharmacist is to make sure their patient is fully informed about the medication that is being given to them.  Pharmacy Counseling is one of the best ways to prevent pharmaceutical errors.

Counseling by the pharmacist with the patient provides many benefits and is also particularly effective in reducing mistakes. Many errors, such as the wrong medication, will be caught during a counseling session.

A good pharmacist will ask:

  1. What did the physician tell you the drug is for?
  2. How were you told to take the medication?
  3. What directions did the physician provide for taking the medication?

The pharmacist can then compare this information with the drug and label and recognize any discrepancies between what the patient says and what the medicine is being used for.

But when a pharmacist is too busy to talk with the patient, or the pharmacist is good at asking the questions, but is not really listening to the patient, then a medication error can happen easily.  As a patient, when you are having you or your family’s prescription filled, take the time to ask questions, make sure the pharmacist meets with you to review the medication.

Make sure that you and the pharmacist agree upon what the medical condition is that the medication is supposed to treat.  Then make certain that you and the pharmacist address the strength of the medication being given to you, and how and when the medication is supposed to be taken.

Then address any complications that may happen due to taking other medications at the same time.  The old adage that an ounce of prevention is better than a pound of cure is certainly applicable when it comes time to pick up your medicine at your pharmacy.


A pharmacy error that causes serious injury or death is an avoidable mistake, and a patient’s worst nightmare.  If you suspect a pharmacy error, here are a few steps you should take immediately to preserve your health and legal rights.

You need to know that the pharmacy has policies and procedures in place designed to protect their rights not yours once a mistake is suspected.  The pharmacists and their staff are trained to immediately obtain possession of the misfilled prescription.

This is so they can “get it away from causing further harm” but in reality it has more to do with eliminating the evidence to be used against them.  I can’t tell you how many times the pharmacy later says something like, well, we saved the bottle for a while, it was on a shelf back there, and I guess someone threw it away.

So, I urge you to hold onto any and all evidence you can to help protect your ability to prove that the pharmacy made a mistake.

I hope you have found this information helpful.  If you have a question, please feel free to call my office and we will be glad to discuss your particular situation and see if there is anything we can do to help.