Where Medication Errors Still Happen and How Pharmacists Can Intervene Earlier

Medication errors, defined as any preventable event that may lead to inappropriate medication use or patient harm, negatively impact at least 1.5 million individuals annually.^1,2 Research shows that an average of approximately 65% of medication discrepancies occurred during patient discharge.³ Through medication therapy management (MTM), however, pharmacists can play an important role in medication error prevention.

Using MTM to Uncover Hidden Medication Risks

A systematic review evaluated how pharmacists help prevent medication errors and assessed the strategies most effective in reducing them.³ Literature searches were conducted through a variety of databases such as PubMed Central, Scopus, Trip, Prospero, Medline, and Google Scholar for papers published between 2010 and 2020. Seven reviewed studies identified the importance of increasing pharmacist interventions, and 5 studies showed that pharmacists have a significant impact in preventing medication errors.³ Additionally, 5 studies supported pharmacist-led education to raise awareness about medication errors. Other strategies studied included work-related approaches and implementing policies for medication error reporting. Overall, the research found that pharmacists are vital to patient safety by preventing medication errors.³  

This aligns with broader international efforts, including the World Health Organization (WHO) Global Patient Safety Challenge: Medication Without Harm.⁴ This initiative was launched in 2017 with the original goal of reducing severe patient harm from medication errors by 50% within 5 years, and is now in its third iteration. According to the WHO, almost 50% of preventable patient harm is associated with medications and therapeutic interventions.

It is important to incorporate a culture of safety in the pharmacy workplace. One key feature of a culture of safety is a blame-free environment in which pharmacists and staff can report medication errors without fear of punishment.⁵ Encouraging collaboration across disciplines and providing appropriate resources are part of a culture of safety to address patient safety problems. Pharmacists should use a systems approach to prevent and identify medication errors. For instance, a physician may make a prescribing error for a medication dosage, but the pharmacist can identify it before the medication reaches the patient by contacting the physician to correct the dose. 

Building on this systems-level perspective, the Institute for Safe Medication Practices publishes a list of look-alike, sound-alike (LASA) drug names that can lead to prescribing and dispensing medication errors.⁶ Ambien (zolpidem; Cosette Pharmaceuticals) and ambrisentan (Letairis; Gilead Sciences, Inc) are an example of a LASA pair. Strategies to prevent medication errors include using brand and generic names on prescriptions and labels and writing the indication. Using tall-man lettering and separating LASA medications in the pharmacy are additional strategies to prevent medication errors.

Assessing for drug interactions and allergies is also a critical part of preventing medication errors. Pharmacists can inquire about this information during MTM consults, when patients can bring their prescription and OTC medications for the pharmacist to check for any drug interactions. These consults can also help identify therapy duplication and polypharmacy. If pharmacists are performing an MTM session via telephone, they should have patients list all medications they are taking.

While evaluating OTC medications, it is important to check that patients are not duplicating medications such as acetaminophen (Tylenol; Kenvue) to prevent accidental overdoses or other harm. There are more than 600 prescription and OTC medications that contain acetaminophen as an active ingredient, making inadvertent duplication easy.⁷ Additionally, pharmacists should educate patients to always read the drug facts label on the back of OTC products so that they have the tools and knowledge to prevent accidents themselves. 

MTM Spotlight

In an email interview with Pharmacy Times, Jennifer D. Goldman, PharmD, CDCES, BC-ADM, FCCP, professor of pharmacy practice at the Massachusetts College of Pharmacy and Health Sciences in Boston, discussed medication error prevention strategies. Goldman is a clinical pharmacist and director of cardiometabolic services at Well Life Medical, an internal medicine practice, where she provides ambulatory care to patients with complex chronic conditions, including type 1 and type 2 diabetes, obesity, chronic kidney disease (CKD), hypertension, and hyperlipidemia.

“Medication error prevention in my practice begins with working under a collaborative practice agreement, which allows me to prescribe and actively manage drug therapy. A foundational step is verifying that correct medication and doses are selected, particularly in patients with complex or frequently changing regimens. I perform medication reconciliation at every visit to identify duplicate therapies,” Goldman said. For instance, through medication reconciliation, Goldman identified a patient taking 2 basal insulins.

Assessing kidney function is also a critical part of Goldman’s practice because many medications require renal dosage adjustments in patients with CKD. Additionally, Goldman routinely evaluates OTC and herbal product use among her patients.

“Patients do not view these products as medications, yet they can meaningfully contribute to adverse effects or drug interactions,” Goldman said.

About the Author

Jennifer Gershman, PharmD, CPh, PACS, is a drug information pharmacist and Pharmacy Times contributor who resides in South Florida.

REFERENCES

1. Medication errors. Academy of Managed Care Pharmacy. Accessed February 5, 2026. https://www.amcp.org/concepts-managed-care-pharmacy/medication-errors

2. About medication errors. National Coordinating Council for Medication Error Reporting and Prevention. Accessed February 5, 2026. https://www.nccmerp.org/about-medication-errors

3. Gillani SW, Gulam SM, Thomas D, et al. Role and services of a pharmacist in the prevention of medication errors: a systematic review. Curr Drug Saf. 2021;16(3):322-328. doi:10.2174/1574886315666201002124713

4. Medication Without Harm Policy Brief. World Health Organization. 2023. Accessed February 9, 2026. https://iris.who.int/server/api/core/bitstreams/1eacccb6-838e-4787-bfd9-4bdeb4debfcf/content

5. Culture of safety. Agency for Healthcare Research and Quality. September 15, 2024. Accessed February 9, 2026. https://psnet.ahrq.gov/primer/culture-safety

6. ISMP list of confused drug names. Institute for Safe Medication Practices. 2024. Accessed February 9, 2026. https://online.ecri.org/hubfs/ISMP/Resources/ISMP_ConfusedDrugNames.pdf

7. Medicines containing acetaminophen. NeedyMeds BeMedWise. Accessed February 9, 2026. https://www.bemedwise.org/health-research-and-reports/health-resources-and-toolkits/acetaminophen/acetaminophen-containing/