To Combat Medication Errors, Proper Pharmacy Inventory Counts Are Essential

Pharmacies have vast and specialized product inventories that require special attention and comprehensive internal controls to increase efficiency and safeguard medicines. Proper handling and organization of pharmacy inventory is a critical component of safe medication packaging, which helps prevent medication error, a scourge on patients that results in countless injuries and billions in complication costs. Concerningly, preventable adverse events due to medication errors cause an estimated 44,000 to 98,000 hospital deaths annually, more than the number attributed to motor vehicle accidents.^1-3

Detect-A-Dose Lid Label Covers. Image Credit: © Medi-Dose, Inc.

Medication packing errors can have consequences due to a litany of occurrences, whether due to packing a higher dose than indicated, packing drugs together with potentially fatal drug-drug interactions, or packing incorrect drugs that may induce allergies or other adverse effects. One of the most common forms is errors of omission, which leaves out packing medications a patient is supposed to be taking. Unfortunately, simple interventions beyond major technological upgrades to inventory systems or utilization of artificial intelligence are lacking.²

A prominent aspect of this issue that manufacturers have tried to tackle is medication recognition when transferring pills to containers and packaging. Consumers often have difficulty identifying pills when they are transferred to a different container, combined into a single container for patient convenience, or portioned into pillboxes. Though these acts are generally well-intended, new tools are required to better aid pharmacists and health care providers in easily identifying often differently colored and sized medications in the packaging process.^1,2

New products are entering the market that could be poised to revolutionize the inventory counting process for pharmacists and health care providers, especially for controlled substances. One such product is the new Detect-A-Dose lid-label cover, produced by Medi-Dose, Inc, which is designed to enhance the recognition of packaged medications through quick visual identification.⁴

Detect-A-Dose features a contrasting black and white pattern on the underside of its label to make missing doses for patients apparent to pharmacists. If the sealed package is tilted in one direction, light-colored medications will contrast with the dark background; if the package is tilted the other way, dark-colored medications will contrast with the light background. This lid label provides a simple solution to the common problem of medication packaging errors, one that can be easily procured and implemented at a pharmacy without major financial hurdles. Furthermore, pharmacists can be easily taught and counseled on how to utilize the product.⁴

“We’re always working to improve the medication packaging experience for pharmacists and nurses,” Robert Braverman, president of Medi-Dose, said in a news release announcing the product. “This enhancement helps ensure proper medication counts and protect against diversion, all while maintaining safety for patients and personnel.”⁴

Pharmacists play an important front-line role in preventing medication errors. Although they are a center of health care and counseling for patients, pharmacies uniquely serve as major storage locations of vast amounts of medications and pills that treat countless conditions. To properly and responsibly allocate these medications to patients, pharmacists and health professionals must develop proper literacy and adeptness at using new products such as Detect-A-Dose while maintaining adequate communication and multidisciplinary teamwork.

REFERENCES

1. Delgado NL, Usuyama N, Hall AK, et al. Fast and accurate medication identification. Npj Digital medicine. 2019:10(2). doi:10.1038/s41746-019-0086-0

2. Mason AN. Pharmacy internal controls: A call for greater vigilance during the COVID-19 pandemic. Pharmacy (Basel). 2020;8(4):216. doi:10.3390/pharmacy8040216

3. Tariq RA, Vashisht R, Sinha A, Scherbak Y. Medication dispensing errors and prevention. National Library of Medicine. Last Updated February 12, 2024. Accessed Online via StatPearls on June 5, 2025. https://www.ncbi.nlm.nih.gov/books/NBK519065/

4. U.S. Pharmacist. Medi-Dose, Inc. announces NEW Detect-A-Dose lid-label covers to enhance recognition of packaged meds. News Release. Released May 20, 2025. Accessed June 5, 2025. https://www.uspharmacist.com/article/medidose-inc-announces-new-detectadose-lidlabel-covers-to-enhance-recognition-of-packaged-meds