P HARMACIES FILL HUNDREDS OF prescriptions daily. During this process in the United States alone, an estimated 51.5 million errors occur during the filling of 3 billion prescriptions each year (Flynn, Barker, & Carnahan, 2003). This translates into an estimated dispensing accuracy rate of 98.3% or, conversely, a 1.7% error rate. Although statistically this is a low error rate, it means that about 4 errors occur each day in a pharmacy filling 250 prescriptions a day. According to Flynn et aI., the chances of a patient's receiving an incorrectly filled new prescription are 1 in 30 and the chances are 1 in 1000 that there will be a clinically important error. What is being done to reduce this already low error rate even further? How can the 3.3 million potentially important errors be minimized to the extent humanly possible? There are numerous factors that can help prevent errors in pharmacies, such as work practices and facility design. For the purposes of the study reported in this article, we focused on one very specific but important consideration: the labels on prescription drugs provided by a manufacturer. In this article, we describe some of the important tasks performed by pharmacy staff, summarize related human factors and pharmaceutical literature, and describe the testing
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