How to Recognize Labeling Errors and Ask for Corrections in Medication Labels

Imagine this: a patient gets a prescription for metformin, but the label says metoprolol. One letter. One typo. That’s not a small mistake-it’s a life-threatening error. In pharmacies across Scotland and beyond, labeling errors happen more often than you think. And when they do, the consequences aren’t just theoretical. They’re real. Patients get the wrong drug. They have adverse reactions. Sometimes, they die.

These aren’t just computer glitches or rare accidents. According to the UK’s National Patient Safety Agency, medication labeling errors contribute to over 250,000 preventable incidents annually in the UK alone. Most of these come from simple mistakes: misread handwriting, incorrect barcode scans, mismatched batch numbers, or labels printed with the wrong drug name. And here’s the kicker-many of these errors go unnoticed until it’s too late.

What Counts as a Labeling Error?

A labeling error isn’t just when the name is wrong. It’s any mismatch between what the drug is supposed to be and what the label says. That includes:

• Wrong drug name (e.g., lisinopril labeled as losartan)
• Incorrect strength (e.g., 500mg instead of 5mg)
• Wrong dosage form (e.g., tablet labeled as capsule)
• Missing or incorrect expiration date
• Wrong patient name or prescription number
• Barcodes that don’t match the label
• Incorrect routing instructions (e.g., oral instead of IV)

These aren’t just clerical slip-ups. They’re systemic failures. A 2024 audit by the Royal Pharmaceutical Society found that 1 in 12 dispensed prescriptions in community pharmacies had at least one labeling inconsistency. Most of these were caught before reaching the patient-but not all.

How to Spot Labeling Errors Before They Reach the Patient

You don’t need a PhD to catch a labeling error. You just need to slow down and look closely. Here’s how:

1. Compare the label to the original prescription. Don’t just glance. Read every word. Check the drug name, strength, quantity, and directions. If it’s handwritten, compare it to the electronic version if available.
2. Verify the barcode. Scan it. If the system says it’s amoxicillin but the label says azithromycin, stop. Don’t dispense. Don’t assume it’s a scanner glitch.
3. Check the look of the pill. If you’re dispensing tablets, compare the color, shape, and imprint to the manufacturer’s description. A 500mg metformin tablet is white, oval, and scored. If it’s blue and round, something’s wrong.
4. Look for duplicate labels. Sometimes, old labels are partially peeled off, and a new one is stuck on top. That’s a red flag. Peel back gently-if there’s more than one label, investigate.
5. Ask yourself: Does this make sense? Why is a 72-year-old with kidney disease getting a high-dose NSAID? Why is a child getting an adult-strength antibiotic? If the prescription doesn’t match the patient’s profile, question it.

These aren’t just best practices-they’re survival tactics. In one Aberdeen pharmacy, a technician noticed the label on a bottle of insulin said "100 units/mL" but the vial was labeled "U-500". That’s five times the concentration. If it had been dispensed, the patient could have gone into a fatal hypoglycemic coma. She caught it because she asked: "Why does this look different?"

How to Ask for Corrections Without Sounding Accusatory

When you find an error, you don’t want to blame someone. You want to fix it. The way you ask matters.

Instead of saying, "You messed up," say:

• "Can we double-check this label against the prescription? I’m seeing a mismatch on the strength."
• "I noticed the barcode doesn’t match what’s printed. Can we re-scan it?"
• "This looks like it might be a mix-up with another batch. Can we pull the original order record?"

Use "we" language. Make it a team effort. Most labeling errors happen because of rushed workflows, unclear instructions, or outdated templates-not because someone was careless.

One pharmacist in Dundee told me she started using a simple script: "I’ve got a question about this label-can we walk through it together?" She found that pharmacists and technicians were far more willing to admit mistakes when they weren’t put on the defensive.

What to Do When the Error Is Already in the System

What if the label was printed, dispensed, and the patient already left? You still have to act.

1. Stop the error from spreading. If it’s a batch issue, quarantine all similar labels. Don’t wait for someone to tell you to.
2. Notify the patient immediately. Call them. Don’t send a letter. Don’t wait. Say: "We found a mistake on your label. You were given the wrong medication. Please stop taking it and bring it back. We’ll replace it right away."
3. Document everything. Record what the error was, how it was found, who was involved, and what was done to fix it. This isn’t just for compliance-it’s for learning.
4. Report it. In Scotland, all serious medication errors must be reported to the Scottish Patient Safety Programme (SPSP). Even if the patient was fine, report it. That’s how systems improve.

One pharmacy in Inverness had a recurring issue with prednisolone being mislabeled as prednisone. After three near-misses, they implemented a new rule: every corticosteroid label must be verified by two people, and the word "PREDNISOLONE" must be printed in bold red letters. The error rate dropped to zero within two months.

How to Prevent Labeling Errors Before They Happen

Prevention is better than correction. Here’s what works:

• Use electronic prescribing. Handwritten scripts are the #1 source of labeling errors. If you’re still using paper, push for e-scripts. They cut labeling mistakes by 70%.
• Standardize label templates. Make sure every label has the same layout: drug name, strength, dosage form, directions, patient name, prescriber, date, and expiration. No variations.
• Train staff on common look-alike, sound-alike drugs. Lasix and Lantus. Zyrtec and Zoloft. Propranolol and Propafenone. These are the usual suspects. Make a list. Post it. Quiz staff quarterly.
• Implement a second-check system. For high-risk drugs-insulin, opioids, anticoagulants-require two people to verify the label before dispensing. It’s slow, but it saves lives.
• Use color coding. Red for high-alert meds. Yellow for narcotics. Green for antibiotics. Visual cues stick better than text.

A 2023 study in the British Journal of Clinical Pharmacology found that pharmacies using these five practices reduced labeling errors by 82% over 18 months. No fancy software. Just better habits.

When to Escalate: Beyond the Pharmacy

Some errors aren’t just mistakes-they’re signs of bigger problems.

If you see:

• Repeated errors from the same supplier
• Labels consistently printed with wrong fonts or missing fields
• Technicians saying, "We’ve always done it this way,"

Then it’s time to escalate. Talk to your manager. Contact the wholesaler. Report it to the Medicines and Healthcare products Regulatory Agency (MHRA). Don’t wait for someone to get hurt.

One pharmacy in Aberdeen stopped using a certain wholesaler after three batches of amiodarone had the wrong expiration date printed. They switched suppliers. The next batch? Perfectly labeled. No more issues.

Final Thought: Your Eyes Are the Best Tool

No algorithm, no barcode scanner, no automated system can replace a trained human who takes a moment to look. Technology helps-but it doesn’t replace vigilance.

Every time you pause before dispensing, every time you double-check, every time you ask a question-you’re not being slow. You’re being safe.

Medication labeling isn’t about paperwork. It’s about people. And the right label? It’s the difference between healing and harm.