Spotting a Medication Error

Published June 15, 2020 (current as of June 20, 2024)

Consumers can often spot a medication error by knowing what to expect. This includes knowing what medicine has been prescribed (for example, the name and dose), what the medicine looks like, and what side effects to expect. The following reported error and great catch shows the importance of knowing about the medicine you take.

A consumer was started on a medicine to control his blood pressure. The dose was later increased from 4 mg to 8 mg per day. After taking the new dose for a few days, the consumer felt overly tired and had low energy. The consumer’s blood pressure reading had also dropped by 40 points. Knowing these were potential side effects of the medicine, the consumer read the label on the prescription bottle and noticed that the strength of the medicine was 16 mg, not the 8 mg that had been prescribed. The consumer contacted his healthcare provider.

Here’s what you can do: While dispensing errors happen infrequently, consumers are the last line of defense and should speak up if something does not seem right. Here are the top 10 reasons to suspect a medication error:

1. The medicine’s appearance (color, shape, markings on the tablet) is different from expected, and the pharmacist did not warn the person about switching to a different manufacturer.
2. The smell or taste is different than expected or extremely unpleasant.
3. The amount of liquid in a syringe or bottle is more or less than expected.
4. The number of tablets or capsules in a prescription bottle is more or less than expected.
5. The directions on a prescription bottle label differ from what your doctor told you.
6. The patient’s name on the label is not as it should appear, including misspellings or incorrect suffixes like Jr. or Sr. if others in your household have the same name.
7. The doctor’s name on the label is not your doctor.
8. The name of the medicine on the bottle label is not as expected.
9. The reason for taking the medicine (in a leaflet or mentioned by the pharmacist) is different from the condition being treated.
10. After renewing a prescription, you experience new side effects or begin to notice physical changes after taking a few doses, such as a change in urine color, unexpected weakness or drowsiness, dizziness, breathing difficulties, racing heart, vision problems, and so on.