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Medication Errors Inconsistently Identified by Community Pharmacists

July 25, 2019

New study findings show that medication errors were not consistently identified by community pharmacists. Further, the results indicate that community pharmacists are not always using interventions known to mitigate medication error risk. The findings of this study were published online in The Journal of Pediatric Pharmacology and Therapeutics.  

The authors of this study sought to assess the competency of community pharmacists in identifying medication errors in pediatric prescriptions. Additionally, they wanted to determine how frequently interventions known to mitigate errors were used.  

The study sought to recognize factors that may impact the pharmacist's ability to identify and mediate these errors, and to detect barriers that limit the role of the pharmacist pediatric patient care,” study authors explained.  

In order to gain a better understanding, the research team distributed a survey among the University of Illinois at Chicago College of Pharmacy Alumni Network and the Illinois Pharmacists Association, as well as pharmacists practicing—within the past 5 years—in a retail setting. Although 161 respondents began the survey, only 138 met inclusion criteria.

The survey consisted of three prescription scenarios for commonly used pediatric medications. Along with each scenario were corresponding questions that assessed the pharmacist’s ability to identify potential medication errors.  

Among 15- to 59% of the scenario-based questions, pharmacists did not appropriately identify errors or interventions that would lower the likelihood of errors, according to the study findings.

Correct identification of doses was associated with total prescription volume in one scenario and with pediatric prescription volume in another scenario,” the study authors wrote. 

The survey findings also showed prescription label inconsistencies. According to the researchers, pharmacists inconsistently labeled prescriptions for oral liquids in milliliters or dispense oral syringes.  

Finally, the study authors noted that barriers to pharmacist involvement included:

  • availability and interest of the caregiver;
  • ability to contact prescriber; and,
  • pharmacy staffing.  

“Community pharmacists did not consistently identify medication errors or use interventions known to mitigate error risk,” concluded the study authors.  

Julie Gould  


Brown SW, Oliveri LM, Ohler KH, Briars L. Identification of Errors in Pediatric Prescriptions and Interventions to Prevent Errors: A Survey of Community Pharmacists [published online July 2019]. J Pediatr Pharmacol Ther. Jul-Aug;24(4):304-311. doi: 10.5863/1551-6776-24.4.304

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