Michael J. Gaunt, PharmD

The use of e-prescribing systems offers gains in efficiency of communication between prescriber, pharmacy, and pharmacy benefit manager, but problems involving electronically transmitted prescriptions still exist.

Drugs with similar names are a threat to patient safety, and pharmacists must be on high alert when filling and dispensing these medications.

Confusing guidelines regarding dosing of some OTC products can potentially harm young children.

Pharmacies must implement and maintain protocols to minimize the risk of errors when compounding and mixing medications.

The lack of response to an error is often the most upsetting part for a patient.

Everyone learns from mistakes. Health care professionals in particular learn a great deal from error-reporting systems and should be encouraged to use best practices to report errors when they occur.

Pharmacists can take precautions to avoid medication errors caused by mixing up drugs with similar-sounding names.

Pharmacists need to not "normalize" stories of tragic events that occur in the pharmacy; rather, pharmacists must learn from the mistakes of others, and take in important information, to ensure the mistakes do not recur.

Recommendations are presented here to prevent dispensing errors with concentrated opioid solutions, which can have devastating consequences.

Placing a prescription "on hold" in the pharmacy computer system and bagging errors are possible causes of medication errors. Tips are presented here to avoid such errors.

Pharmacists can assist school systems in developing and implementing procedures for medication administration and storage.

Pharmacy technicians play a major role in helping prevent medication errors-our columnist presents strategies to foster communication and prevent errors from occurring.

Studies have shown that patients often have a poor understanding of their health conditions and recommended treatment. Pharmacists play an integral role in addressing this problem by employing strategies that reinforce patient comprehension.

Poor health literacy is a barrier to adherence for many patients. Pharmacists can implement several strategies to help patients use medications safely.

Pharmacists should provide appropriate devices for measuring medications and ensure that the patient or caregiver understands how to properly use the device.

Our 2009 resolutions should include stepped-up efforts to prevent drug name mix-ups and reduce dispensing errors.

Attention should be paid to drug name suffixes to prevent mixups.

Suggested strategies are presented to help avoid medication errors and subsequent harm with opiates. Errors resulting from these high-alert medications can cause allergic reactions, seizures, and even death.

Pharmacists should take precautions when dealing with these drugs.

Verifying prescriptions by checking the National Drug Code's 4-digit product identifier is not enough; duplication of these "middle 4" numbers can cause product mix-ups in pharmacies.

Many medications have been mixed up because of poorly handwritten prescriptions?2 particular mix-ups are presented here, as well as suggestions to prevent them from occurring again.

Various foreign medications have names that are very similar, if not identical, to unrelated US drugs; several are reviewed as reminders in this article, along with recommendations to avoid confusion.

Several similarly named prescription drugs are often confused and dispensed in error.

Proper reaction to near misses is essential in preventing medication errors, and this column features useful advice on developing systembased, error-reduction strategies.

To avoid medication mix-ups, all practitioners should be encouraged to have orders read back and spelled out.