The One Question I Think Every Pharmacist Should Ask

If I could give a pharmacist one simple piece of risk management advice, something that costs nothing, takes only a few seconds, and could potentially prevent a serious medication error, it would be these 10 words:

“Hey, what did your doctor tell you this is for?”

That’s it.

Ten words.

But after years of working around pharmacy risk and seeing the kinds of situations that can turn into serious claims, I believe those ten words can be one of the most effective final checks a pharmacist has.

Why This Question Matters

Think about the moment when a patient is standing at the counter.

The prescription has been processed. The medication is in the white bag. The patient is ready to leave.

Before handing it over, the pharmacist asks:

“Hey, what did your doctor tell you this is for?”

The patient's answer provides one more piece of information that can be compared against the medication being dispensed.

Sometimes, that simple conversation can reveal that something doesn't make sense.

For example, imagine the patient answers:

“Narcolepsy.”

But the medication in the bag is Ativan instead of Adderall.

Say those two drug names out loud: Ativan. Adderall.

They aren't identical, but they're similar enough that in a busy healthcare environment, it's not difficult to understand how one could be heard, remembered, communicated, or selected incorrectly.

And that's an important part of the risk-management lesson.

Not every medication error is the result of someone being reckless or incompetent. Sometimes it's an experienced healthcare professional working through a busy day who hears something incorrectly, remembers a similar-sounding name, selects the wrong medication, or simply makes an honest human mistake.

The mistake may be simple.

The consequences may not be.

A patient expecting a stimulant used in the treatment of narcolepsy who instead receives a medication such as Ativan, which can cause significant sedation, could face an entirely different risk than either the patient or pharmacist anticipated.

That's why those ten words can be so valuable.

When the patient says, “My doctor told me this is for narcolepsy,” the pharmacist suddenly has another reason to look at that bottle and ask:

Does what I'm about to hand this patient make sense?

When an Honest Mistake Becomes a Serious Claim

This isn't just a theoretical concern.

I know of a situation involving a patient being treated for narcolepsy who received the wrong medication. Instead of the medication the patient expected, the patient took a medication that caused significant drowsiness.

The patient later fell asleep while driving and was involved in a severe automobile accident.

Fortunately, the patient survived.

That's the difficult reality of medication errors. Something that begins with a very small mistake can have consequences far beyond the pharmacy counter.

And that's also why I don't think the useful lesson from situations like this is simply, “Be more careful.”

Pharmacists are already careful.

The better question from a risk-management standpoint is:

Can we create one more opportunity to catch the mistake?

The Last Check Doesn't Have to Be Complicated

Risk management can sound complicated.

Policies. Procedures. Documentation. Technology. Training. Quality-control systems.

All of those things matter.

But some of the most effective risk-management practices are remarkably simple.

A short conversation at the counter can provide information that wasn't available from the prescription alone.

What does the patient believe they're being treated for?

Does that answer make sense considering the medication you're about to hand them?

If it doesn't, stop.

Take another look.

Ask another question.

A few seconds is a small price to pay for another opportunity to catch an error.

Protecting More Than a Prescription

A serious medication error can potentially lead to a professional liability claim, a Board of Pharmacy complaint or investigation, defense expenses, reputational damage, and, in particularly serious situations, questions surrounding a pharmacist's professional license.

Those are important risk-management considerations.

But they aren't the most important reason to ask the question.

It isn't a replacement for the pharmacy's other safeguards.

It's simply one more chance to catch an honest mistake before it becomes a costly one.

And ultimately, that's what good risk management is about.

Pharmacists don't put safeguards in place simply because they're worried about claims, lawsuits, or their professional license. They do it because there is a real person standing on the other side of that counter who is trusting them to get it right.

Most pharmacists I know take that responsibility very seriously.

So before that white bag crosses the counter, take a few seconds and ask:

“Hey, what did your doctor tell you this is for?”

Ten simple words. One more opportunity to protect the patient who trusted you with their care.

For a broader look at the coverage considerations for your practice, visit the pharmacy insurance page.