Strategies for Effective Medication Error Prevention in Community Pharmacy

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm. These are unintended breakdowns in the treatment process that may occur at any stage and may or may not harm the patient.¹

According to the World Health Organization, medication errors result in at least 1 death daily and injure 1.3 million people annually in the United States. Worldwide, the annual cost of medication errors is estimated at $42 billion, which is nearly 1% of total global health expenditure.²

Combating medication errors at the community pharmacy level is of critical importance, as this is often the final checkpoint in the medication use process before the drug reaches the patient. Medication error rates in dispensing are low, but the sheer volume of medications dispensed daily leads to many errors.¹

Causes of Medication Errors

Human factors coupled with systemic weaknesses within the community pharmacy workflow are usually at fault for medication errors.¹

High workloads and staffing issues in community pharmacies are a prevalent safety issue. Also, significant importance is placed on pharmacy metrics. These factors create a hurried environment in which critical safety procedures, such as thorough data entry review, screening for drug interactions, and detailed patient counseling, are often rushed.

Community pharmacies are dynamic, with constant interruptions and distractions. The incessant demands of ringing phones, patient questions, drive-through interactions, and staff communication take the pharmacist’s attention away from critical tasks, increasing the likelihood of medication errors.

Communication breakdowns in community pharmacy can also significantly contribute to medication errors. These breakdowns can be between health care providers, among pharmacy staff, and with patients and can create a cascade effect, increasing the risk of an error slipping through various checkpoints.³ Lookalike and soundalike medication errors also pose a significant risk in community pharmacy, despite existing safeguards.⁴

Knowledge and training gaps among pharmacy staff can compromise the pharmacy’s ability to perform critical tasks accurately and to prevent potential safety issues. This can include inadequate drug knowledge and insufficient procedural training.

Additionally, although technology has been used to prevent medication errors, system and technology issues can introduce new risks in community pharmacy. These issues can include interoperability and data transfer problems, poor user interface, alert fatigue, system functionality and maintenance issues, and overreliance.

Finally, patient factors can significantly increase the risk of medication errors in community pharmacy through incomplete patient information, low health literacy, physical and cognitive limitations, and language or cultural barriers. Effective medication management requires active patient involvement and understanding.

Prevention Strategies and Best Practices

Comprehensive strategies are crucial for minimizing the risk of medication errors in community pharmacies and maintaining patient safety. These strategies can include workflow and process optimization, data entry and verification processes, dispensing and product management, technology, and patient engagement.

Implement and strictly follow written, standardized policies and procedures for each step of the prescription process. Organize workflow in a way that promotes a steady, focused, and clear mindset. Minimize interruptions and limit multitasking when performing critical tasks, such as final verification, to prevent errors that can occur due to divided attention. And implement a double-check system for all prescriptions, particularly high-alert medications and those with complex calculations.⁵

Clarify any prescription uncertainties with the prescriber, and document the encounter. Obtain a complete list of patient allergies and conditions as well as all medications, both prescription and over the counter, and document them in the patient profile. Use standardized nomenclature, and avoid the use of abbreviations. For lookalike or soundalike medications, write both the brand and generic names to prevent confusion. Finally, follow decimal point rules: Use leading zeros before a decimal point (eg, 0.1), and avoid using trailing zeros after a decimal point (eg, 1.0).

Medications should be stored in an organized and tidy fashion. Lookalike or soundalike medications should be clearly labeled or stored in separate locations. Once used, medications should be promptly returned to their place on the shelf to avoid clutter and confusion. Ensure medications inside the prescription bottle match the description on the prescription label, and use clear, concise directions.

Technology enhances patient safety through the use of electronic medical records, automated dispensing, drug interaction screening, and barcode scanning. Technology is a support tool, and pharmacy staff should not become complacent and/or automatically override system alerts due to alert fatigue. Pharmacy staff must remain attentive to the warnings and alerts provided by technology to reduce patient harm.

Every new prescription requires a thorough consultation using open-ended questions and verification of patient understanding. Encourage patients to be active members of their health care team by knowing their medications and indications and by asking questions. When patients experience a transition of care, work with them to conduct a thorough medication reconciliation to ensure accurate and updated information.

Creating a Culture of Safety

Creating a culture of safety in community pharmacies is important for patient welfare. Foster a blame-free environment where pharmacy staff feel comfortable reporting medication errors and near misses without the fear of punishment. These errors then become valuable learning opportunities and allow the pharmacy to document and analyze systemic issues. Regular review and discussion of medication errors and near misses can identify trends that can be mitigated through targeted training and process updates, improving medication safety.

Finally, providing continuous professional development opportunities and training on medication safety, industry changes, and updated procedures can help reduce medication errors and improve patient safety.

Conclusion

Reducing medication errors in the community pharmacy requires a multifaceted, systems-based approach. Pharmacists and health care organizations must prioritize patient safety and implement reasonable strategies to reduce medication errors in community pharmacies. The near future will see strategic integration of advanced technology, improved collaboration between health care professionals, and a continued shift toward patient-centered care.

About the Author

Kathleen Kenny, PharmD, RPh, earned her doctoral degree from the University of Colorado Health Sciences Center. She has more than 30 years of experience as a community pharmacist and works as a clinical medical writer based in Albuquerque, New Mexico.

REFERENCES

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2. WHO launches global effort to halve medication-related errors in 5 years. News release. World Health Organization. March 29, 2017. Accessed December 11, 2025. https://www.who.int/news/item/29-03-2017-who-launches-global-effort-to-halve-medication-related-errors-in-5-years

3. Tan R, Kawaja A, Ooi SP, Ng CJ. Communication barriers faced by pharmacists when managing patients with hypertension in a primary care team: a qualitative study. BMC Prim Care. 2024;25(1):100. doi:10.1186/s12875-024-02349-w

4. Supapaan TS, Songmuang A, Napaporn J, et al. Look-alike/sound-alike medication errors: an in-depth examination through a hospital case study. Pharm Pract (Granada). 2024;22(2):1-13. Accessed December 12, 2025. https://www.pharmacypractice.org/index.php/pp/article/view/2959

5. Desai R, Gupta A. The impact of workflow optimization on patient safety and service quality. IJRIPP. 2024;1(2):1-8. Accessed December 12, 2025. https://jagunifiedinternational.in/wp-content/uploads/2024/09/IJRIPP-Vol.12-1-July-2024.pdf