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Oregon News: Labeling Errors
Published in the November 2008 Oregon State Board of Pharmacy Newsletter
An interesting and completely preventable medication labeling error has been reported to the Board. The correct medication label had been applied directly to the container, which was then inserted back into the manufacturer’s box for dispensing. This medication was not picked up by the patient and was returned to stock unused. On a later date, when another prescription for the same medication for a different patient was received, the pharmacist labeled the box without looking at the container inside and dispensed it to the patient. When the patient got home, the box was discarded and the patient noticed that the label on the medication contained somebody else’s name. This same type of error has been reported to the Board twice in recent months. Pharmacists, pharmacy technicians, and interns must continually be aware of potential hazards and always, always double check.
