Evaluating sample medications in primary care: a practice-based research network study

Jt Comm J Qual Patient Saf. 2006 Dec;32(12):688-92. doi: 10.1016/s1553-7250(06)32091-0.


Background: No reports have objectively evaluated safety of samples in primary care practices. A study was conducted to determine adherence to the Institute for Safe Medication Practices (ISMP) recommendations for safe distribution of medication samples to minimize medication errors.

Methods: In 2004, 17 urban and rural primary care practices participated in a two-phase observational study: (1) a site visit to collect inventory data and perform assessment of medication sample dispensing procedures and (2) a survey questionnaire for providers and patients upon sample medication provision.

Results: No practices were compliant with all seven ISMP recommendations. Twelve of 17 practices had policies for sample medication dispensing, and 7 had policies for labeling. Sample medication use was evaluated for 585 office visits and 27 patient surveys. Fifty-eight sample medications were dispensed during 55 of 585 patient visits. Common reasons for using sample medications included availability and need for a short-term trial for a chronic medication. Verbal communication only was provided most of the time for patient education regarding appropriate sample medication use and side effects.

Discussion: Primary care practices in this research network did not follow safe and appropriate sample medication dispensing procedures as outlined by ISMP. Both labeling and patient instructions were inadequate and may increase the risk for medication errors.

Publication types

  • Multicenter Study
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Colorado
  • Communication
  • Drug Labeling
  • Drug Utilization Review / standards*
  • Guideline Adherence / statistics & numerical data
  • Humans
  • Medical Audit
  • Medication Errors / prevention & control*
  • Organizational Policy
  • Patient Education as Topic / standards*
  • Pharmaceutical Preparations / standards
  • Pharmaceutical Preparations / supply & distribution*
  • Physician-Patient Relations*
  • Primary Health Care / standards*
  • Safety Management*


  • Pharmaceutical Preparations