In the book, Chapter 4 focuses on preventing mistakes, including methods like checklists and mistake-proofing.

We should really try to avoid and prevent medication mistakes, considering the harm that can result (up to and including death). We can try to prevent mistakes while also emphasizing the need to learn from each one that still occurs.

A friend sent a story about his experience with two major pharmacy chains, their automated voice response systems, and how they try to prevent a mistake:

I was noticing the difference in the phone-based prescription refill services of Rite Aid versus Sam’s Club.

For Rite Aid you enter your 12-digit, all numeric, prescription number.  For a verification step, the system reads back to you the same, 12-digit number.  It is a form of mistake-proofing, but computers are good with numbers – not people.

At Sam’s Club you enter your 7-digit, all numeric, prescription number.  For a verification step, the system reads back to you the first four letters of the last name associated with the prescription – which is a lot easier for a human to process.  It also better matches the reality of the situation – if you enter the wrong script number someone else’s script could get filled – not yours.

I could see if being very difficult to pay attention to a 12-digit number. Are you supposed to write it down and compare it to what you entered (or what you thought you entered)?

For the Sam’s process, there’s a small chance that you’d enter an incorrect 7-digit number and get a different person’s last name that starts with the same first four letters as yours.

That might be better, but it’s still not perfectly mistake proofed.

So that said, it’s important to always double check the name on your prescription bottle, to make sure you were given the correct one.

But, you also have to check to make sure they didn’t put the wrong medication into the correct bottle. Compare the label’s description of what the pills look like to what’s actually in the bottle.

Or you can look up the photo of a pill online to confirm that it’s correct.