Pharmacy Error Proofing Example


Here is a great example of error proofing that I've never seen before. It's springtime, so my allergies have been killing me, especially after mowing the lawn on Saturday. I went and got a prescription for Allegra and received the new generic equivalent.

Walgreens put a diagram on the information sheet that allows you to confirm that you have the right pills, which is especially helpful here because the generic doesn't have an Allegra logo on there.

Walgreens should almost draw more attention to the purpose of the diagram. I can confirm that I was given a round peach colored pill of that size. I can also confirm that it says “93” on one side and “7253” on the other. I know I have the right pill.

It's not ultimate error proofing. That would be on the pharmacy side, anything they would have in place to make sure the pharmacist couldn't give me the wrong pill. Maybe they have standard work that says they have to confirm the pills against this printout.

It's scary, but there are some medical expert estimates that say about 3% of all prescriptions are wrong (at hospitals or drugstores), which includes wrong pill or wrong dosage.

Walgreens should really have a huge page that says “HEY CUSTOMER! Double check that we gave you the right pill!!!” That would probaby be bad for business though.

A good tip for everyone…. double check anything you get from the drug store. They aren't perfect… they're human after all.

Update: May 30

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.


  1. thanks for posting this – I also just picked up a new ‘script for generic Allegra from Walgreens and received the new round pill instead of the oblong one I was used to. Since I don’t have a PDR laying around I figure the internet could confirm that it is indeed fexofenadine. (didn’t even look at the info sheet! LOL) Your blog was in the top 3 when I googled pill 93 7253, then I confirmed at community. I worked in hospitals for over 5 years and human error happens every day so I want to second your tip.

  2. Me too. My doctor made the substitution without telling me; I’m glad to have found this page explaining why I’ve got round pills instead of the oblong ones. BTW, my google search was Allegra 93 7253. This was page hit No. 2.

  3. all drugs are assigned an NDC or national drug code. It comes in the format of 99999 9999 99. Most manufacturers put the middle 4 digits on the pill excluding the leading zeros. The first 5 ids the manufacturer, the middle 4 ids the drug, and the last two is the package form

    the full NDC should be on most prescrition labels


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