If an automated pharmacy system selects an incorrect drug, what is the required corrective action?

• A. The system should be shut down immediately and not used again
• B. Pharmacy staff should document the incident and continue as normal
• C. Only the drugs that were flagged need pharmacist verification
• D. 100% of all drugs must be verified by a pharmacist until a cause is determined and the problem is fixed

Answer: (D)

When an automated dispensing system selects an incorrect drug, patient safety requires a thorough, corrective action that stops the potential harm from spreading and finds the root cause. The best move is to have a pharmacist re-check all dispensed medications—100% verification—until the underlying issue is identified and fixed. This approach acts as a safety net, catching any other wrong drugs that might have been dispensed and giving time to diagnose whether the error came from a barcode mismatch, database error, labeling problem, or workflow flaw. Simply documenting the incident and continuing as normal leaves ongoing risk, and verifying only the flagged items could miss other misdispenses. Shutting the system down entirely is an extreme step that isn’t the standard corrective action needed to restore safe operation, whereas full pharmacist verification ensures patient safety while the investigation and fixes are completed.