The red pen rules: How to prevent pharmacy error


Anxious new pharmacists get a shot in the arm from columnist Pete Kreckel, RPh.


I come from a family of hard-working, hands-on men. My brother Don is a welder. One of his favorite expressions is "dung runs downhill" (okay, Don uses another word). I think of this often, because essentially, the guy in the white coat is at the end of the pipe. 


Irate customers, unhappy docs, and pharmacy staff all expect the pharmacist to be the final authority. As a teacher and preceptor, I have observed that a lot of students don't seem to be ready for this responsibility, not to mention the ultimate job of the pharmacist: to make sure that the right medication goes to the right patient. If this fails, your ability to recite Micromedex from memory is of no value.

Our ultimate charge is to get the right medication to the right patient, and to give that patient the educational information needed to support the most positive outcome.


I interact with a lot of student pharmacists, and I like to bounce ideas off their heads. One student pharmacist, Sophia, is in her last rotation from Pitt. She is bright, energetic, and full of anticipation about her professional future. When I asked her what she would like to see in this article, she asked me to address the concept of "hand-holding."

Hand holding concerns students who about to graduate and are afraid to make decisions. In the community pharmacy environment, these decisions would pertain specifically to checking an Rx, dispensing it, and "letting go."

While they were students, young pharmacists-to-be had their hands held, meaning that they had no ultimate responsibility. Now, as newly fledged pharmacists, they are the ones at the end of the counter. They are the final check. Often they find that ultimate responsibility daunting. To these new pharmacists, I say: just don’t let it become overwhelming.

There’s a first time for everything. I still remember the first prescription I checked, on my first day as a new pharmacist, in August 1981. It was for Benadryl 50-mg capsules.


I was talking with a pharmacist last week who has been practicing for over 20 years in a major retail chain. She admitted that her OCD was getting the best of her, to the extent that it interfered with her work. She seemed so stressed and helpless. She was not enjoying this profession for what it can be.

This is what I shared with her.

Keep in mind, I told her, that most errors in the pharmacy can be traced back to an interruption. To ensure that I have the peace of mind of knowing that I checked that prescription, my technique is to minimize interruptions.

The red pen

I have a red pen. When I have the red pen in my hand, no one is permitted to talk to me or interrupt me.

Checking prescriptions is a two-step process. Some chains have broken this down so that these operations can be done at two different sites!

Step 1: Verify that the label that was generated matches the original orders, by marking the paper prescription with the red pen.

Step 2: Verify that the correct drug is in the container. Where I work, we have a bar-code verification system operated by our filling tech that verifies a matching bar code and counts pills. I check the label on the bottle and verify the name and strength. I then take the red pen and circle the middle block of the NDC (National Drug Code).

Once everything is verified, the prescription moves away - either to the pickup bin or to the cashier to ring up. I also flag the prescription receipt for pharmacist consultation, if I feel it is necessary. To ensure that the prescription goes to the correct patient, the cashier verifies the date of birth.

Pull the trigger

Using the red pen is a physical act. I can look at the prescription paper and the receipt to physically observe that indeed, I verified the prescription, and to “pull the trigger.”

To Sophia and her peers, I say, now put down the red pen and go interact with these patients, who truly need the benefit of your expertise!

We all worry about mistakes happening. We know we bear the ultimate responsibility. I sweat it every day. A pharmacist who doesn't worry is the most dangerous one around!

Pete Kreckelpractices independent community pharmacy in Altoona, Penn. He welcomes your e-mails

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