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MEDICATION ERRORS: Just Because We Sound and Look Alike Doesn’t Mean We are Alike

Submitted by Meditec on Mon, 02/16/2015 - 16:47

The most important thing pharmacy technicians can do in a pharmacy is to check and double check their work. The next most important thing is to make sure the pharmacist checks and signs off on every prescription filled in the pharmacy—it is law. I have had personal experience with medication errors. I went to have a prescription medication filled for my son’s asthma. The medication he needed was prednisone. He had been prescribed this medication many times before, so I knew which drug it was and what I should expect at the pharmacy. However, when I went to pick up his prescription and as I was reviewing what they had filled, I noticed the drug was in liquid form instead of the pill form. I told the pharmacist that my son had a pill from a couple of months ago for this same medication. They had filled my son’s prednisone prescription with prednisolone. It was a different drug that sounded alike and was very similar but was not the same medication. The pharmacist tried to convince me that prednisolone was what had been prescribed and not prednisone. I asked them to double check to make sure, and after checking he came back and said “I am sorry we missed that! You are right it was for prednisone.’’ The pharmacist had signed off on this medication to be dispensed to me, and somewhere in the process an error was made. This error would have affected my son’s therapy and would not have been good for his treatment. It was a big error on their part and one that happens far too often. My story highlights that it is not only important to check prescriptions as a pharmacy technician but also to be very aware of “sound alike and look alike” drugs. It is recommended for Pharmacy Technicians to review the list of Sound Alike and Look Alike List of Drugs posted by: The ISMP (Institute for Safe Medication Practices) is working with the FDA in reducing medication errors by helping medical staff to be more aware of medication name similarities and dissimilarities. Pharmacy technicians play a crucial part in preventing medication errors. It all begins by Technicians learning the most commonly prescribed medications and familiarizing themselves with their classification, use, and their generics. Technicians use different study methods in learning these drugs via electronic flashcard, for example those found in or Pharmacy Technicians should constantly be on the lookout for possible sources of medical errors. Adopt safety-oriented work practices to ensure the safety of patients and to avoid adverse patient outcomes.


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