Pharmacists Can Intervene in Commonly Overlooked Medication Errors

Medication errors remain a frequent challenge in clinical practice, with many commonly used medications often prescribed or ordered incorrectly. Discrepancies can arise from inappropriate drug selection, incorrect dosing, administration routes, or misaligned therapeutic goals. Pharmacists play a vital role in identifying and resolving these issues through clinical judgment and collaboration with other medical providers (eg, physicians, dentists, pulmonologists, psychiatrists, etc.). Below are several common errors encountered in daily practice and examples of how individualized patient care and pharmacist involvement can minimize or avoid these errors completely.

Medication errors remain frequent | Image credit: sutlafk | stock.adobe.com

Error #1: Using Buspirone As Needed for Anxiety

Buspirone (Buspar; Bristol Myers Squibb) is commonly prescribed for generalized anxiety disorder (GAD) and off-label for unipolar depression.^1,2 Buspirone acts as a serotonin (5-HT1A and 5-HT2) receptor agonist.¹ It is generally well tolerated, and carries no risk of abuse, dependence, or withdrawal.¹ However, buspirone requires 2 to 4 weeks to achieve therapeutic effect, making it ineffective for acute, “as needed” relief of anxiety.^1,3

If acute anxiety relief is needed, consider alternatives such as hydroxyzine (Vistaril; Pfizer), which has shown comparable efficacy to benzodiazepines in a Cochrane review.^2,4 Clinicians can also consider a benzodiazepine, when clinically appropriate and for a short-term duration.^2,5

Error #2: Initiating Lamotrigine at Therapeutic Doses

Lamotrigine (Lamictal; GSK) is an antiepileptic drug used for bipolar disorder depression, seizures, and migraines.⁶ While rare (less than 1%), initiating at higher doses or titrating too quickly can increase the chances of developing severe skin reactions such as Stevens-Johnson syndrome or toxic epidermal necrolysis.^6,7 These dermatological conditions can be severe and even life threatening. When started at lower doses and titrated slowly, the risk is just 0.1% to 0.01%. Benign skin rashes, however, still occur in about 10% of patients.⁸

Flag prescriptions that start lamotrigine at full therapeutic doses without proper titration. Consult prescribers about starting lamotrigine low and titrating up to prevent serious adverse reactions.^7,8

Error #3: Relying On Docusate Despite Limited Evidence

Docusate (Colace; Atlantis Consumer Healthcare, Inc.), a stool softener, remains one of the most prescribed laxatives, is generally considered safe, and has been available for a long time. Despite widespread use, it has no FDA-approved indication and minimal supporting clinical evidence. Available studies show no significant benefit over placebo for acute or chronic constipation.^9,10

Instead of docusate, consider other options. Encourage non-pharmacologic measures (hydration, dietary fiber, prune juice, etc.) first. If those are ineffective, consider evidence-based agents such as polyethylene glycol (MiraLAX; Bayer Corp.).⁹ Some sources recommend evaluating whether docusate should remain in treatment protocols given its questionable efficacy and cost implications.¹¹

Error #4: Overuse of Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease

According to the most recent Global Initiative for Chronic Lung Disease (GOLD) guidelines, which are updated annually, a bronchodilator, long-acting beta agonists (LABA) or long-acting muscarinic antagonists (LAMA), either individually or in combination, are first-line therapies for COPD.¹² ICS should be reserved as add-on therapy, not initial treatment.¹³ Despite this, ICS overuse remains, with data suggesting 50% to 80% overuse in some studies.¹⁴

Data suggest limiting use of ICS to patients in GOLD Group E and those with a history of hospitalization(s), frequent or severe exacerbations, concomitant asthma, or elevated blood eosinophils (approximately 10% of the COPD population).^12,14 When an ICS is warranted, consider triple therapy, not in lieu of a LABA and/or LAMA. Avoid routine ICS use due to limited benefits and to reduce risks, such as pneumonia and fractures.^13-15

Error #4: Incorrect Dose Adjustments of Apixaban

Apixaban (Eliquis; Bristol Myers Squibb, Pfizer) is indicated for nonvalvular atrial fibrillation, venous thromboembolism, and postoperative venous thromboprophylaxis.¹⁶ It is known that apixaban dose decreases from 5 mg twice daily to 2.5 mg twice daily if a patient meets at least 2 of the following criteria: serum creatinine 1.5 mg/dL or greater, age 80 years or older, and/or body weight 60 kg or less.^16,17 A common error is reducing apixaban to once-daily dosing (5 mg daily or 2.5 mg), which is unsupported by clinical trials.^16,18 With apixaban’s short 12-hour half-life, patients may not be able to always be at a therapeutic level.¹⁹ Underdosing of anticoagulants can increase risk of stroke or systemic embolism by 22%, whereas overdosing raises bleeding risk by 30%.¹⁸

Maintain twice-daily dosing when possible. Also, consider that apixaban is 27% renally excreted and has drug-drug interactions with CYP3A4 and P-glycoprotein.¹⁹

Error #5: Underutilization of Statins in Patients With Diabetes and Normal Cholesterol

In medication therapy management, pharmacists often recommend statins for patients with diabetes, but prescribers often decline if cholesterol levels appear normal. However, statin benefits such as reduced rates of cardiovascular morbidity and mortality are independent of baseline low-density lipoprotein (LDL) levels in patients with diabetes and other cardiovascular risk factors.²⁰ Current guidelines recommend a moderate- or high-intensity statin therapy for all patients with diabetes aged 40 to 75 years regardless of the estimated 10-year Atherosclerotic Cardiovascular Disease risk, and for patients with a target LDL reduction of 30% to more than 50% depending on their 10-year atherosclerotic cardiovascular disease risk.^21,22

Remind prescribers and patients that extremely low LDL levels and addition of statins have been shown to be safe and are associated with improved survival.²³ Continue to monitor statin-specific adverse effects and drug interactions.

Conclusion

Pharmacists are uniquely positioned to prevent common medication errors through careful evaluation, patient counseling, and collaboration with prescribers. By addressing issues such as inappropriate as-needed buspirone use, improper lamotrigine initiation, reliance on docusate, apixaban underdosing, COPD treatment missteps, and statin underutilization, pharmacists can significantly improve patient safety and therapeutic outcomes.

REFERENCES

1. NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK531477/ . Published August 21, 2025. Accessed August 21, 2025.

2. Clinical Resource, Pharmacotherapy of Anxiety Disorders in Adults. Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber Insights. April 2024. [400401]

3. Payne, G. https://www.nami.org/NAMI/media/NAMI-Media/Research/Buspirone.pdf . Published August 31, 2023. Accessed August 21, 2025.

4. Barbui, C. Hydroxyzine for generalised anxiety disorder. PubMed. https://pubmed.ncbi.nlm.nih.gov/21154375/ . Accessed August 21, 2025.

5. https://www.acofp.org/docs/default-source/ofp/vol-7-no-1-(2015)-january-february-2015/the-current-role-of-long-term-benzodiazepines-for-the-treatment-of-generalized-anxiety.pdf?sfvrsn=ff26af2c_0 . Published December 8, 2014. Accessed August 21, 2025.

6. NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK470442/?report=reader . Published September 4, 2025. Accessed September 4, 2025.

7. Clinical Resource, Pharmacotherapy of Bipolar Disorder in Adults. Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber’s Letter. June 2023. [390625]

8. Aiken, C. How to Minimize Lamotrigine’s Adverse Effects. https://www.psychiatrictimes.com/view/how-minimize-lamotrigines-adverse-effects . Published February 13, 2018. Accessed August 22, 2025.

9. Clinical Resource, Management of Constipation. Pharmacist’s Letter/Prescriber’s Letter. January 2023. [390108]

10. NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK555942/ . Published August 22, 2025. Accessed August 23, 2025.

11. Engle AL, Winans ARM. Rethinking Docusate's Role in Opioid-Induced Constipation: A Critical Analysis of the Evidence. J Pain Palliat Care Pharmacother. 2021;35(1):63-72. doi:10.1080/15360288.2020.1828529

12. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: 2025 Report. Global Initiative for Chronic Obstructive Lung Disease website. https://goldcopd.org/2025-gold-report/. Published November 15, 2024. Accessed August 28, 2025

13. NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK608187/ . Published September 4, 2025. Accessed September 4, 2025.

14. Quint JK, Ariel A, Barnes PJ. Rational use of inhaled corticosteroids for the treatment of COPD. Npj Primary Care Respiratory Medicine. 2023;33(1). doi:10.1038/s41533-023-00347-6

15. Cochrane. Do inhaled steroids increase the risk of pneumonia in people with chronic obstructive pulmonary disease (COPD)? Cochrane. April 2025. https://www.cochrane.org/evidence/CD010115_do-inhaled-steroids-increase-risk-pneumonia-people-chronic-obstructive-pulmonary-disease-copd.Sent

16. hcp.eliquis.com. Dosing Guide for All Adult ELIQUIS Indications. https://www.eliquis.com/assets/buildeasy/us-commercial/eliquis-hcp/en/resources/pdf/Eliquis-Dosing-Guide-Desktop-Version.pdf

17. Sign in. Factsandcomparisons.com. Published 2025. Accessed September 3, 2025. https://eanswers.factsandcomparisons.com/lco/action/doc/retrieve/docid/fc_dfc/5548428?cesid=5I7oEpTn47T&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Deliquis%26t%3Dname%26acs%3Dfalse%26acq%3DELIQ%26nq%3Dtrue

18. Shurrab M, Ryu R, Jackevicius CA. Off-Label direct oral anticoagulant dosing: caution advised. Circulation Cardiovascular Quality and Outcomes. 2021;14(12). doi:10.1161/circoutcomes.121.008608

19. Quick reference guide to apixaban. PMC . https://pmc.ncbi.nlm.nih.gov/articles/PMC5513886/ . Accessed September 3, 2025.

20. Eldor R, Raz I. American Diabetes Association Indications for Statins in Diabetes: Is there evidence? Diabetes Care. 2009;32(suppl_2):S384-S391. doi:https://doi.org/10.2337/dc09-s345

21. AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. Circulation. 2019;139(25). doi:https://doi.org/10.1161/cir.0000000000000625

22. Lloyd-Jones DM, Morris PB, Ballantyne CM, et al. 2022 ACC Expert Consensus Decision Pathway on the Role of Nonstatin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk: A Report of the American College of Cardiology Solution Set Oversight Committee. Journal of the American College of Cardiology. 2022;80(14). doi:https://doi.org/10.1016/j.jacc.2022.07.006

23. Leeper NJ, Ardehali R, deGoma EM, Heidenreich PA. Statin Use in Patients With Extremely Low Low-Density Lipoprotein Levels Is Associated With Improved Survival. Circulation. 2007;116(6):613-618. doi:https://doi.org/10.1161/circulationaha.107.694117