Medication errors can be reduced by patient counseling

April 1, 2009

Students in a University of Florida healthcare risk management class examine the connection between medication errors and patient counseling from the dual perspective of pharmacists and risk managers.

Key Points

Most pharmacists would have answered the question posed in class - "Can counseling reduce medication errors?" - with a shrug and say "Of course."

Interestingly, the students looked at the question not as practicing pharmacists might, but as risk managers. The question became not just "Can counseling reduce medication errors?" But "Why?" "What type counseling would be required?" And "What kinds of errors could be reduced?" The students also looked at possible barriers to counseling.

The answer to that question, the students suggest, requires a discussion of the nature of counseling and the nature of effective counseling. Reviewing the legislation and rules in several states, the students found requirements by regulations are limited. The best counseling to enable pharmacists to detect mechanical errors, according to the publications researched, follows the APhA and ASHP guidelines, which are more complete.

If time is a factor, then extensive counseling may best be used selectively, with the pharmacist using professional judgment to determine which prescriptions pose higher risks. For example, NTI drugs, such as warfarin, are involved in more claims than any other drug, according to the Pharmacists Mutual study. It is not because pharmacists make more mistakes with warfarin prescriptions; they do not. Drugs that show up in claims, however, tend to have a greater potential for serious harm if an error reaches the patient. These drugs require additional cautions on behalf of the pharmacist. Therefore, such drugs might be placed on a special communication list and marked for a higher degree of counseling.

Ultimately, it is up to the state Board of Pharmacy, to which the report is presented, to determine whether counseling is likely to be an effective way to reduce medication errors and whether regulation is an effective way to guide the process.

KEN BAKER is a pharmacist and an attorney. He consults in the areas of pharmacy error reduction and risk management. Contact Ken Baker at