Survey: staffing shortages lead to dangerous medication mistakes in Dutch pharmacies

Thousands of medication errors occur in Dutch pharmacies every year, with serious consequences for patients, according to a survey of 2,730 pharmacy assistants conducted by EenVandaag. More than half of the respondents stated that the absence of a mandatory second check—known as the four-eyes principle—sometimes leads to mistakes during medication dispensing. These errors are often a result of staff shortages and high workloads that make it difficult for pharmacy assistants to carry out the necessary checks.

Pharmacy assistants explained that sometimes medications are dispensed before a second check can be performed or only a trainee is available to do the double-checking. A significant number of assistants also reported working alone when opening or closing the pharmacy, with 25 percent saying they are uncomfortable with this situation due to the lack of additional checks.

Medication errors include dispensing the wrong drug, giving it to the wrong patient, or providing the incorrect dosage. These mistakes often go unnoticed when the process is not overseen by another qualified staff member. Cor Toorenburg, a 70-year-old patient, shared his experience of receiving an incorrect dosage of painkillers after a recent surgery. "I was prescribed too much oxycodon," Toorenburg told EenVandaag. "After taking the medication, I became disoriented and fell down the stairs. I had to be rescued by an ambulance, but I was lucky it didn’t end worse."

The underlying issues, pharmacy assistants say, stem from chronic staff shortages and excessive workloads. "I often find myself alone with a trainee who has to perform the second check. That’s just not sufficient," one assistant revealed, requesting anonymity due to the pressure they face from employers. Others described how, at the end of their shifts, they are required to review a long list of medications that have already been dispensed.

Anke Lambooij, of the Institute for Responsible Medicine Use (IVN), emphasized the importance of the second check. "We know that the four-eyes principle has helped prevent incidents at the last moment," Lambooij told Een Vandaag. "It’s vital for medication safety that two independent people conduct a careful check."

In March, pharmacy assistants were informed that their salaries would increase by 20 percent by the end of 2026, a step welcomed by the FNV labor union. However, union officials stress that this is not a solution to the root causes of the problem. Ralph Smeets of FNV Zorg en Welzijn argued, "Working alone or with a trainee does not meet legal requirements. It’s simply insufficient."

While Lambooij acknowledged that many patients do intervene when they notice discrepancies in their medications, she reiterated the importance of addressing these issues to prevent harm. She suggested that pharmacy assistants and pharmacists might consider prioritizing high-risk medications for the second check, especially those that could have more serious consequences if dispensed incorrectly.

Cor Toorenburg, the patient who fell, now pays extra attention when picking up his medications. "I don’t blame the pharmacy assistants," he said. "They’re wonderful people, but they are being forced into this situation."

The Royal Dutch Society for the Advancement of Pharmacy (KNMP), the professional association of pharmacists, is expected to provide a response to these concerns later today.