Patients: Last defense in preventing medication errors

ISMP Error Alert

Pharmacists can engage patients as active partners in their care by educating them about their medications and about ways to avert errors.


Advise patients that medication errors can occur and that they can play a role in preventing these errors. An alert and knowledgeable patient can serve as the last line of defense in preventing medication errors. We have many reports in our database of errors that were prevented by observant and informed patients or their families. To prevent errors, patients must receive ongoing education by physicians, pharmacists, and nurses about drug brand and generic names, indications, usual and actual doses, expected and possible adverse effects, drug or food interactions, and ways to protect themselves from errors.

Patients can play a vital role in preventing medication errors when they are encouraged to ask questions and seek satisfactory answers about their medications before drugs are dispensed at a pharmacy. If patients question any part of the medication dispensing process—whether it is to question the drug appearance or the dose—pharmacists must be receptive and responsive, not defensive. All patient inquiries should be investigated thoroughly before the medication is dispensed. Table 1 lists strategies pharmacists should discuss with patients.

Table 1. Consumer measures for error protection1,2

  • Be aware that medicine mix-ups from look- and sound-alike names are not uncommon.
  • Make sure your doctor tells you the purpose for each medication and writes it on the prescription itself.
  • Know the name and strength of a prescription before leaving the prescriber’s office.
  • When you pick up a prescription, always speak to the pharmacist to review the medication and directions for taking it.
  • Make sure the pharmacist mentions the same purpose the doctor mentioned to ensure that the right drug has been dispensed.
  • Know how to take medications and understand directions.
  • Keep a list of medications you take, including dietary supplements and OTC medications.
  • Update the medication list whenever a change occurs.
  • Give an updated copy of your medication list to all health care providers at every visit.
  • Learn generic drug names as key identifiers.
  • Ask for written information about prescribed medications.
  • Contact a health professional if a look- and/or sound-alike error is suspected.

Tragedy, recommendations

A 17-year-old female track athlete died following the use of OTC muscle pain relief cream (e.g., Bengay, Icy Hot). The high school student reportedly used a methyl salicylate cream to treat myalgia following track meets. In addition to spreading the cream on her legs, she was using other methyl salicylate–containing products.

Pharmacists can use this tragedy as a reminder to educate patients about their use of OTC products. Pharmacists should be easily accessible to speak with patients when they select OTC medications. Educate patients about the dangers of methyl salicylate overuse and warn them that it is available in many OTC products. Use “shelf talkers” near methyl salicylate and other selected OTC products to raise awareness. See Table 2 for other ways that pharmacists help patients function as an independent check and prevent medication errors.

Table 2. Patient education: Suggested risk reduction strategies

  • Use vials large enough to contain all of the medication and also large enough to have all necessary labels comfortably affixed.
  • Teach patients how to participate in the proper identification of the medication actively before accepting it at pickup.
  • Provide patients and caregivers with brand and generic names of their medications, the purpose of the medication, dosing, and important adverse effects orally and/or in writing.
  • Update patient profiles in the computer system to include all drug products currently being taken—prescription or not, received from this pharmacy or not—and keep these other products in mind when counseling and performing drug use reviews. Inform patients of interactions, duplications, and dangers.
  • Using a “teach-back” method, provide patients with instruction on proper use and maintenance of devices dispensed from the pharmacy.


  1. Institute for Safe Medication Practices. Accessed at, June 22, 2012.
  2. Rados C. Drug name confusion: preventing medication errors. FDA Consumer. 2005;39(4). Accessed at…, June 22, 2012.