What to expect when a pharmacy makes a mistake


Most people realize human error can happen, including when getting a prescription filled at the pharmacy. Although pharmacists do their best, mistakes sometimes happen. Thanks to safer medicine labels and technologies like barcode scanning, mistakes of the past are rapidly declining. The few pharmacy errors that do slip by usually do not cause serious or permanent harm. Still, that’s little consolation to a consumer who is harmed or could have been harmed if a more serious error had happened.  

When pharmacy mistakes happen, consumers are sometimes more upset about the response they receive from the pharmacy than they are about the error itself. They may feel that the pharmacist, technician, or pharmacy manager has responded poorly when confronted with the possibility of a dispensing error. A consumer error report we received provides a perfect example.

After picking up a refill for alprazolam (Xanax) to treat anxiety, a consumer noticed that the pills were white, not blue as she expected. She assumed that the pharmacy had switched to a different generic medicine, so she took one tablet as prescribed. Two hours later, she took another tablet because she was still feeling anxious. Several hours later, she called her doctor, who advised her to take two additional tablets. Still feeling anxious, the consumer called the pharmacy after she started shaking, felt cold and jittery, and her mind and heart were racing. The pharmacist asked about the color and markings on the tablets, and then told the consumer that they were a thyroid medicine. He then suggested that the consumer talk to the pharmacy manager the next day to exchange the thyroid medicine for the correct medicine. That was it. No apology, no empathy for the consumer’s adverse reaction, nothing! The next day, the pharmacy manager offered no apology either. She just exchanged the pills and said, “Hope you feel better.” The consumer had not slept all night and was still feeling ill. But that was it—the total pharmacy response.

While this poor response is clearly not typical in all pharmacies, it suggests that some pharmacy staff have not been trained to respond properly when a consumer reports an error. Instead, consumers are simply asked to return the wrong medicine to the pharmacy and then they are given the correct medicine. Some pharmacies may also offer a discount coupon or refund for the cost of the wrong medicine. Pharmacy staff may truly want to be more responsive to consumers who report errors. However, they may be required to follow pharmacy policies that, due to legal concerns, may not encourage pharmacy staff to apologize for the error, explain how it happened, or share what will be done to avoid similar errors in the future.

Here’s what you can expect:  If you think there may be a mistake with your prescription medicine, don’t hesitate to let your pharmacy staff know, even if a prior experience has been unsatisfactory. If there has been a mistake, it is reasonable for you to expect the pharmacy staff to do the following:

  • Make time to talk to you immediately.
  • Treat you with respect.
  • Acknowledge that a mistake has happened and offer an apology.
  • Inform your doctor about what happened (if you have taken any doses of the wrong medicine).
  • Advise you to see your doctor or go to the hospital (if you may have been harmed or put at risk by taking the wrong medicine).
  • Investigate the cause of the mistake with your medicine.
  • Come up with an action plan to avoid similar mistakes in the future.
  • Let you know about the action plan and how it will be put in place.


Created on June 7, 2017

Medication Safety Alerts

FDA Safety Alerts

Show Your Support!

ISMP needs your help to continue our life saving work