Understanding the factors that increase the risk of medication errors is essential to help reduce errors.

The Food and Drug Administration estimate 1.3 million injuries are due to medication errors in the United States each year. This means, according to some reports, medication errors are the third leading cause of death in America.

If your patients were to hear of these alarming statistics, they would pay closer attention to the medication you prescribe, and the treatment plan you create. But typically, your patients trust you and simply follow your directions, blindly.

Therefore, it is so important you recognize all the factors that increase the risk of medication errors.

Medication Errors Defined

The Food and Drug Administration states that a medication error occurs when you give a patient medication and as a result, they are harmed in some way. They also consider medication errors to be preventable, had more attention been provided by you, the patient, caregiver or the pharmacy.

Drug Name Confusion

The Institute for Safe Medication Practices created a list of medications that sound alike. These medications, if confused for one another, can bring harm to the person ingesting them.

For example, clonidine can be easily confused with clonazepam or klonopin. Getting these two confused can create dangerously low blood pressure levels, which can lead to a life or death situation is not corrected right away.

The best way to avoid drug name confusion is to use software technology that can alert you to these similarities, encouraging you to double and triple check your prescription. Software associated with in-office dispensing not only does this, but it also alerts you to any negative interactions with the patient’s other medications.


Labels are small, yet they are required to show a great deal of information. Everything from the names of both doctor and patient, to name of medication, dose and side effect warnings are listed on a label.

Even if all the information on a label is correct, a patient can misinterpret some of the information, putting them at risk. It’s important to avoid using abbreviations which can be confusing for patients.

If you are prescribing medicine at the point of care, you are most likely using technology that prints the label for you. This makes it so easy for you because you do not have to enter all information every time you prescribe.

The labeling software program will auto-fill much of the information, including your contact information, brand and generic name of medicine, potential side effects, patient information, refill number and dose instructions.


Everyone makes mistakes. But when mistakes can risk the life of a patient, changes need to be made. This is true when it comes to ensuring the correct dose is understood by the patient. It’s important you double check your prescription and make sure the patient understands the dose you are recommending.

If you want your patient to take 7.5 mcg of a drug, make sure they do not confuse this with 75 mcg. One small decimal point can cause a medication error with negative consequences. This is also an area that could be helped with software technology designed to assist you in catching possible errors.

Patient Mix-Up

You are busy, pharmacists are busy, and medical staff in hospitals and nursing homes are busy. Because of this, mistakes are made, like getting patients mixed up and giving them medication that was meant for another patient.

An example is this story, in which a nurse gave a patient a paralytic instead of an antacid, killing the patient. And this is not the only story with a negative ending.

While not all cases are this severe, they can still be damaging.


Most medicines come in a plastic container with a protective lid. All the pills for the prescription are placed in this same container, as a group. This is fine, except for the patients who have a hard time remembering if they took their medication.

When they can’t remember they have two options: skip their medicine for that day or take a pill with the chance of taking a double dose.

There are packaging options available that prevent medication errors. Prepackaged medicine has enormous benefits for patients and can be individually packed to prevent mistakes.

Patient Confusion

When you are discussing treatment plans with your patients, they seem to understand your instructions. Many times, though, they have no clue what you are talking about. Maybe they are too scared to ask questions. Maybe they feel insecure about asking you to repeat something.

So, they leave your office confused. This confusion can lead to patients guessing as to how they are supposed to carry out their treatment plan. Errors are made, and patients suffer.

The best way to avoid patient confusion is to make educating them a priority. If you are dispensing in office, this is easy. The dispensing software you use allows you to print every single bit of information about a medication and a prescription.

Once printed, you can spend time with your patient reviewing the information to ensure they are aware of why it is needed and how to properly consume it.

Prevention Tips

Medication errors can be prevented. There are several tips you can follow to make your practice, and your patient, safer. One thing you can do is train your staff to double check everything, from identification of patient to chart notes, to ensure they are correct.

You can also slow down. Yes, you have many patients to see and it seems as if there are not enough hours in the day. However, just taking a few extra minutes with patients to make sure they understand their medical issues and your instructions for treatment, can go a long way in preventing errors.

Utilize the benefits that come with in-office dispensing, which puts you more in control of the medicine your patients receive. Pharmacists are making more errors today than in previous years. Dispensing allows you to monitor your patient throughout the treatment process.

You provide better health care and your patients see greater outcomes, helping you reach your goals as a physician.