Every year, over 1.5 million people in the U.S. are harmed by mistakes in their prescriptions. Many of these errors happen before the medicine even leaves the doctor’s office. It’s not always the pharmacist’s fault. It’s not always the pharmacy’s fault. Often, the mistake starts with how the prescription was written - and if you don’t know what to look for, you might never catch it until it’s too late.
What Kind of Errors Happen on Prescriptions?
Prescription errors aren’t rare. They’re common - and often invisible. A handwritten note saying "U" for units can be mistaken for "0," turning a 5-unit dose into 50 units. That’s a tenfold overdose. A decimal point written as ".5" without a leading zero can be read as "5," turning a safe dose of insulin into a deadly one. Between 2010 and 2020, these tiny mistakes caused 128 deaths, according to the FDA. Other errors are just as dangerous but less obvious:- Wrong drug name: "Celebrex" vs. "Celexa" - one treats arthritis, the other depression. Mix them up, and you’re treating the wrong condition.
- Wrong dosage: "5.0 mg" instead of "5 mg" - the trailing zero can be misread as 50 mg.
- Confusing abbreviations: "QD" (once daily) mistaken for "QID" (four times daily). "MS" for morphine sulfate confused with "MgSO4" for magnesium sulfate - one calms pain, the other treats seizures.
- Missing instructions: No indication like "for high blood pressure" or "for diabetes." Without it, you can’t tell if the medicine is right for you.
- Wrong frequency: "Take once daily" written as "Take every 4 hours" - that’s six times more medicine than intended.
Why Do These Errors Keep Happening?
You might think electronic prescribing fixed this. It helped - but it didn’t solve everything. In fact, a 2019 JAMA study found that while electronic systems cut handwriting errors by 55%, they introduced 34% new types of mistakes. Why? Because doctors are rushed. On average, they spend just 17 seconds writing each prescription in busy clinics. A 2022 survey showed 68% of primary care doctors make at least one prescribing error every month. Internists average 2.3 errors per month. The system is broken in ways we don’t talk about. Dropdown menus in e-prescribing systems list drugs in alphabetical order. If you’re looking for "5 mg" of a drug, you might accidentally pick "50 mg" because it’s right below it. Safety alerts pop up constantly - and 31% of doctors just click past them. That’s called a "workaround." It saves time. It also kills people. And then there’s the language problem. Doctors still use abbreviations like "U" for units or "QD" for daily, even though they’re banned by safety guidelines. A 2022 audit found only 58% of prescriptions followed the basic rules: use full words, include the reason for the drug, and write doses with leading zeros (0.5, not .5).What You Can Do: The 7-Point Prescription Checklist
You don’t need to be a doctor to catch a mistake. You just need to know what to look for. The FDA recommends checking your prescription for these seven things before you leave the office or pick up your medicine:- Full drug name - No abbreviations. "Lamotrigine," not "Lamictal." "Insulin glargine," not just "insulin."
- Precise dosage - Always written with a leading zero for doses under 1 (0.5 mg, not .5 mg). No trailing zeros (5 mg, not 5.0 mg).
- Clear frequency - "Take once daily," not "QD." "Take two times a day," not "BID."
- Total quantity - If you’re supposed to take one pill a day for 30 days, you should get 30 pills. Not 10. Not 100.
- Reason for the drug - "For high blood pressure," "for pain," "for anxiety." If it’s missing, ask.
- Prescriber’s contact info - Name, phone, license number. If it’s missing, the prescription might not be valid.
- Expiration date - Prescriptions expire. Most are only good for 6 to 12 months. Don’t take an old one.
High-Risk Drugs: Know the Danger Pairs
Some drugs are more dangerous than others. The Institute for Safe Medication Practices (ISMP) keeps a list of "error-prone drug pairs" - names that sound or look alike. Here are the most common ones:- Celebrex (arthritis) vs. Celexa (depression)
- Zyprexa (schizophrenia) vs. Zyrtec (allergies)
- Hydrocortisone (skin cream) vs. Heparin (blood thinner)
- Lamotrigine (seizures) vs. Lamictal - the brand name. Using the brand name alone can cause dosing errors.
Use the Teach-Back Method
Don’t just nod and leave. When your doctor or nurse tells you how to take the medicine, repeat it back in your own words. This is called the "teach-back" method. Say: "So, I take one 5-milligram tablet every morning with food, right? And it’s for my blood pressure?" Johns Hopkins Medicine found this simple trick reduces misunderstandings by 81%. It forces the provider to confirm they said it right - and gives you a chance to catch a mistake before you walk out.Verify Electronic Prescriptions
If your doctor sends the prescription electronically, you still need to check. Pharmacies get the order, but they don’t always know why you’re taking it. When you pick up your medicine, compare the label to what you were told:- Is the name correct?
- Is the dose right?
- Does the frequency match?
- Is the reason listed?
Use the "Ask Me 3" Questions
The National Patient Safety Foundation created a simple tool called "Ask Me 3." It gives you three questions to ask every time you get a new prescription:- What is my main problem?
- What do I need to do?
- Why is it important for me to do this?
Technology Can Help - But Don’t Rely on It Alone
There are apps now that scan your prescription and flag errors. One called MedSafety, used by over 2 million people, reduced patient-identified errors by 68% in a 2023 study. Some hospitals now send automated text alerts with your prescription details - and when patients got these, error detection jumped from 29% to 74% within 24 hours. But technology isn’t perfect. If you have low health literacy - which affects 36% of U.S. adults - these tools won’t help much. That’s why human verification still matters. No app can replace asking, "Is this right?"What to Do If You Find a Mistake
If you spot a problem:- Don’t take the medicine.
- Call your doctor’s office immediately. Ask to speak to the prescriber or their nurse.
- Ask them to reissue the prescription with the correct details.
- If the pharmacy has already filled it, ask them to hold it while you confirm.
- If you’ve already taken the wrong dose, call Poison Control (1-800-222-1222) or go to the ER.
The Future Is Changing - But You Need to Act Now
By 2025, all electronic health records will let you see your prescriptions in real time through your phone. By 2030, doctors may be required to get your digital confirmation before a prescription is sent to the pharmacy. That’s progress. But right now, the system still fails. And the burden of catching errors still falls on you. You don’t have to accept a dangerous prescription. You don’t have to guess if the medicine is right. You have the power to stop a mistake before it hurts you. Start today. Check your next prescription. Ask the questions. Say no to shortcuts. Your life depends on it.Can a pharmacist catch a prescription error if the doctor made it?
Yes, pharmacists are trained to catch errors - but they’re not mind readers. If the prescription says "0.5 mg" but the doctor meant "5 mg," the pharmacist won’t know unless you tell them. Pharmacists spend nearly 19 minutes per prescription verifying details, up from 6 minutes in 2015 - and over 40% of that time is spent fixing prescriber mistakes. Still, they can’t catch everything. That’s why patient verification is critical.
What if my doctor gets upset when I ask questions about my prescription?
Good doctors welcome questions. If your doctor reacts poorly, that’s a red flag. Your safety matters more than their ego. You have the right to understand your treatment. If they dismiss you, ask for a second opinion or find a new provider. Many clinics now train staff to respond to patient questions with patience - because it reduces errors and improves outcomes.
Are handwritten prescriptions still common?
Not in most clinics - but they still happen. About 15% of prescriptions are still handwritten, especially in urgent care centers, rural clinics, or when e-prescribing systems crash. Even in digital systems, doctors sometimes print out a paper copy and handwrite changes. Always check for "U," "QD," or missing decimals - even if the prescription looks electronic.
How do I know if a drug is high-risk?
High-risk drugs include insulin, warfarin, heparin, morphine, fentanyl, and other opioids, seizure medications like phenytoin, and chemotherapy drugs. If you’re unsure, ask your pharmacist: "Is this a high-alert medication?" They’ll tell you. These drugs require extra caution - always double-check the name, dose, and reason.
What should I do if I accidentally took the wrong medication?
Call Poison Control at 1-800-222-1222 immediately. They’re available 24/7 and can guide you on what to do next. If you’re having symptoms like dizziness, trouble breathing, chest pain, or confusion, go to the ER. Don’t wait. Even small mistakes with high-risk drugs can become life-threatening within hours.
Can I request an electronic copy of my prescription?
Yes. Under federal rules, you have the right to access your medical records - including prescriptions - through your provider’s patient portal. By 2025, all systems must let you see prescriptions in real time. If you don’t see yours, ask your doctor’s office to send it to your portal. Having it in writing helps you verify it later.
Do pharmacies have to verify prescriptions before filling them?
Yes - but their verification is limited. Pharmacists check for drug interactions, dosage limits, and allergies. They don’t verify whether the drug is appropriate for your condition unless you tell them. That’s why you need to speak up. If your prescription says "for migraines" but you have high blood pressure, they won’t know unless you say so.
Sohini Majumder
December 1, 2025 AT 06:58