How to Prevent Wrong-Patient Errors at the Pharmacy Counter
Dec, 4 2025
Every year, thousands of people walk into a pharmacy to pick up their prescription - and walk out with someone else’s medicine. It’s not a rare mistake. It’s a preventable one. Wrong-patient errors happen when a pharmacist or technician hands a medication to the wrong person at the counter. The patient might get a drug they’re allergic to. Or worse - they might miss their own life-saving medication because it was given to someone else. These aren’t hypothetical risks. They’re real, documented, and costing lives.
Why This Happens More Than You Think
It’s easy to assume that pharmacists are always careful. But human error isn’t the main problem - the system is. Most wrong-patient errors occur because staff rely on memory, visual cues, or rushed routines. Sound-alike names like Michael Smith and Michael Smyth cause confusion. Same birth dates. Same last names. Same pickup time. And in a busy pharmacy during lunch rush, it’s easy to hand over the wrong bottle. According to the Institute for Safe Medication Practices, wrong-patient errors are among the top causes of serious harm in community pharmacies. A 2022 report from the Agency for Healthcare Research and Quality found that medication errors send about 1.3 million Americans to the emergency room each year. A significant portion of those are due to someone getting the wrong drug because they were misidentified at the counter.The Two-Step Verification That Saves Lives
The single most effective way to stop wrong-patient errors? Ask for two pieces of identifying information - every single time. That means: full name and date of birth. Not just the last name. Not just the first name. Not just a nod and a smile. You need both. And you need to compare them to what’s on the prescription label and in the pharmacy system. This isn’t optional. It’s the standard. The Joint Commission, the National Association of Boards of Pharmacy (NABP), and the American Society of Health-System Pharmacists (ASHP) all require it. CVS, Walgreens, and Walmart have made this mandatory since 2015-2018. And it works. A 2022 analysis of 15,000 pharmacies showed that using name and date of birth together cut wrong-patient errors by 45%. But here’s the catch: if you only ask once, and the person says the right answer, you can’t assume they’re telling the truth. A family member might pick up a prescription and know the patient’s DOB. A fraudster might guess it. That’s why you need to verify - not just ask.Barcode Scanning: The Game Changer
Manual checks help - but they’re not enough. The real breakthrough came with barcode technology. Today, many pharmacies use patient ID cards with barcodes. When the patient arrives, the tech scans their card. The system instantly matches the barcode to the prescription in the queue. If it doesn’t match? The system won’t let the transaction go through. Walgreens rolled this out across 9,000 stores in 2021. Within 18 months, wrong-patient errors dropped by 63%. That’s not a small win. That’s life-saving. Even better? When you combine barcode scanning with the two-identifier check, the error rate plummets to just 11% of what it was before. A 2023 study in the Journal of the American Pharmacists Association found that pharmacies using both methods reduced wrong-patient errors by 89%. The cost? Around $15,000 to $50,000 per location for hardware and software. For big chains, that’s a drop in the bucket. For small independent pharmacies? It’s a hurdle. But the cost of getting it wrong - lawsuits, lost licenses, patient harm - is far higher.
What About Patients Who Hate Being Asked?
Some patients get annoyed. Especially older adults. They’ve been going to the same pharmacy for 20 years. They know the staff. Why do they have to keep proving who they are? A 2024 ECRI Institute survey found that 68% of patients appreciate the extra checks. They feel safer. But 22% find it frustrating - especially if they’re asked the same question twice, or if the staff doesn’t explain why. The fix? Don’t just ask. Explain. Say: “I need to confirm your name and birth date to make sure you get the right medicine. We’ve had cases where someone else picked up a prescription, and the patient didn’t get their heart pill. We don’t want that to happen to you.” Simple. Human. Clear. Pharmacies that train staff to explain the reason behind verification - not just enforce it - see fewer complaints and higher compliance. It turns a chore into a shared safety practice.What About the Staff?
It’s not just about the patient. It’s about the people behind the counter. A pharmacy technician in Ohio posted on Reddit in February 2025: “We started asking for name, DOB, and prescription number. Our store used to have 3-4 wrong-patient errors a month. After 11 months? Zero.” But not everyone has that success. A Walgreens pharmacist in Texas wrote in March 2025: “Barcode systems slow us down during rush hour. People get mad. Managers pressure us to skip steps.” That’s the real danger: pressure to cut corners. When a pharmacy is understaffed or understocked, the temptation to rush is high. That’s when mistakes happen. The solution? Empower every staff member to stop the process if something feels off. You don’t need permission. You don’t need approval. If the name doesn’t match, if the DOB seems wrong, if the barcode doesn’t scan - pause. Ask again. Call the prescriber. Verify again. Dr. Beth Kollisch from ECRI Institute says the pharmacies that eliminated wrong-patient errors all had one thing in common: a culture where anyone - even a new tech - can say, “Wait, this doesn’t look right.”What’s Next? Biometrics and AI
The future is already here. Walgreens started testing fingerprint verification in 500 stores in January 2025. Preliminary results show 92% accuracy. But privacy concerns are slowing rollout. Other pharmacies are testing voice recognition and facial matching. Dr. Robert99 from Lumistry predicts that by 2027, 70% of pharmacies will use AI-assisted identification systems. These tools could reduce wrong-patient errors to near zero. But here’s the truth: no technology works unless people use it right. A barcode scanner won’t help if the tech doesn’t scan it. An AI system won’t catch a mistake if the staff ignores the alert. The best system is the one that combines tech with trained humans who are empowered to speak up.
How to Make It Work in Your Pharmacy
If you run a pharmacy - or work in one - here’s how to start fixing this today:- Make name and date of birth mandatory for every pickup. No exceptions.
- Train every staff member to verify against the label AND the system. Don’t just trust the screen.
- Install barcode scanning if you can. Even a basic system cuts errors in half.
- Explain the “why” to patients. Don’t just ask - educate.
- Create a no-blame culture. If someone catches a mistake, thank them. Don’t punish them for slowing things down.
- Log every near-miss. Track patterns. Are errors happening at certain times? With certain names? Use that data to adjust.
What If You’re the Patient?
You’re not powerless. If you’re picking up a prescription:- Know your date of birth. Have your ID ready.
- Check the label before you leave. Does the name match yours? Does the drug look right?
- If you’re unsure, ask: “Can you double-check this is for me?”
- Don’t be afraid to speak up. You’re not being difficult. You’re protecting your life.
