Implementing a Medication Identification System in Retail Pharmacies to Reduce Medication Error Rates


Author/Creator ORCID



Type of Work


University of Baltimore. Yale Gordon College of Arts and Sciences.


University of Baltimore. Master of Science in Interaction Design and Information Architecture.

Citation of Original Publication


This item may be protected under Title 17 of the U.S. Copyright Law. It is made available by the University of Baltimore for non-commercial research and educational purposes.



The prescription medication dispensing process in community and retail pharmacies has long been recognized as a process allowing for human error that can then lead to medication dispensing errors. One of the conditions that increase the risk of medication errors is the competing tasks faced by many pharmacy staff. In addition to filling and dispensing prescriptions, pharmacists and other pharmacy staff are tasked with counseling patients, administering vaccines, speaking to patients and providers over the phone, and even more, depending on the position. Recommended changes in the field of pharmacy include reducing staffing workload and implementing in community pharmacies some of the technological solutions used in hospitals. These solutions primarily face cost barriers, leading to resistance from major commercial pharmacies. This research study explores the potential to leverage technology that already exists in the community pharmacy setting to reduce dispensing errors. Specifically, the study focuses on testing the effectiveness of a medication identification system at the point of contact with users picking up prescriptions in community retail pharmacies. Ten total users took part in the study. All participants were currently prescribed a minimum of two prescription medications. Participants were given two scenarios during the user testing session, one in which the medication they were given matched the medication they were shown on the verification screen and one that did not match. User tests showed that a pill identification system could be a successful solution to medication dispensing errors, as all ten participants were able to successfully identify in the second scenario that the medication which they were given did not match the medication they were shown on the prototype. Qualitative results confirmed that the system was regarded as easy to use. Additionally, the System Usability Scale Questionnaire results confirmed that the medication identification system was helpful and easy to use. The implementation of this system in retail pharmacies is likely to assist in the identification of medication dispensing errors and help protect patients from potential harm.