This commentary presents two cases highlighting common medication errors in retail pharmacy settings and discusses the importance of mandatory counseling for new medications, use of standardized error reporting processes, and the role of clinical decision support systems (CDSS) in medical decision-making and ensuring medication safety.

The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.

A 93-year-old man on warfarin with chronic heart failure, atrial fibrillation, and a ventricular assist device (VAD) was admitted to the hospital upon referral from the VAD team due to an elevated internal normalized ratio (INR) of 13.4. During medication review, the hospital team found that his prescribed warfarin dose was 4 mg daily on Mondays and Fridays and 3 mg daily on all other days of the week; this prescription was filled with 1 mg tablets. However, his medication list also included an old prescription for 5 mg tablets.

This case involves a 65-year-old woman with ongoing nausea and vomiting after an uncomplicated hernia repair who was mistakenly prescribed topiramate (brand name Topamax, an anticonvulsant and nerve pain medication) instead of trimethobenzamide (brand name Tigan, an antiemetic) by the outpatient pharmacy.