Tips to checking a prescription safely

There has been an increase in prescription errors in the media. You don’t believe me here are just a few:

  1. Pharmacy in St Albans gives wrong medication. Click here 

2.Family sue pharmacy after grandmother died from wrong medication. Click here

We as professionals must support each other by sharing best practice. The way I check RX was learnt during my time at Sainsbury. First carry out a clinical check through the following process:
1. Check that the medication is suitable for the condition – ensure according to guidelines i.e. NICE
2. Check that the dose is appropriate for the condition
3. Check that the medication does not interact with current medication
4. Check for allergies

Then pick the medication ensure you do NOT use the labels but the Prescription itself to select the products from the shelf. This is important because if you make a mistake on the labels you automatically transfer that mistake when selecting the product. Ensure your checking space is free from clutter and avoid distractions i.e. mobile phones. Now lay the products on the checking table ideally in the order of the prescriptions. Now here is what I picked up from sainsburys and a lot of locums do this. Once you have labelled the medications, when checking use the prescription and physically mark the name of the drug, strength, expiry date and a little mark on patient details i.e. name and address. Since it is a physical process ensures you have read the label. Also if you split the product and place in a new white box ensure that the product batch, expiry details is stated. This is important as the product maybe subject to a recall in which case there would be no way for the patient to know. Remember always get a second person to check if possible and if the medication is a fridge item or controlled drug try and ensure the patient checks the medication. Patients can be used as a barrier to errors as well. Remember they may have been using their medication for a long time. Also take your time do not be afraid to check with the doctor or another pharmacy or the NPA helpline.


Finally, there is no substitute for a mental break – processes will fail if there is no mental break.


Other useful resources:





I hope this blog is useful. Please share tips in the pharmacist forum section or below this blog.

Kind regards,



Pharmacistweb team


    • Faraz BPharm - 11th September 2016

      All above points I affirm .
      ((1)) The amount of light in the checking area is directly proportional to the number of errors – a study showed ; Consider a full spectrum table lamp in the final check area .
      ((2)) Have a mental break between 1st and 2nd do some other checks or dispensing.
      ((3)) Do not remove the original container from the dispensed item – unless it is 2nd checked.
      ((4)) If you are on your own – self check – but do it in reverse -name> form> strength>quantity >dosage >expiry :: expiry > dosage>quantity >strength >name .
      ((5))May help to whisper what you are reading to yourself.
      ((6))Place the Label nearest the largest print on the OP you are dispensing..ignore ‘dispenser place label here’ manufacturers codswollop .Obv do not cover expiry.

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