5 common GLP-1 medication errors pharmacists need to know: ISMP

The Institute for Safe Medication Practices has identified five recurring medication errors involving GLP-1 therapies as use of the medications continues to grow for diabetes and obesity treatment, according to a June 25 news release.

The findings come as GLP-1 safety concerns have mounted alongside rapid growth in prescribing. The FDA warned a GLP-1 compounder over serious safety and compliance violations in January 2025, and counterfeit GLP-1 products have proliferated in recent years — with the FDA issuing warning letters to multiple companies over unapproved and misbranded semaglutide and tirzepatide products. 

Here are the five errors identified by ISMP:

1. Dosing confusion: Prescriptions written in milligrams or milliliters can create dosing errors when syringes are marked in units. ISMP recommends patients and providers confirm the prescribed dose and unit of measurement at every step.
2. Dispensing errors: Because GLP-1 doses are often adjusted monthly, patients should verify they receive the correct dose each time they pick up or receive a prescription.
3. Multi-dose pen misuse: Patients should follow dosing instructions rather than estimating doses by counting clicks or splitting doses.
4. Reusing single-dose vials: Single-dose vials do not contain preservatives and should be discarded after one use. Once punctured, they should not be stored for later use.
5. Counterfeit or substandard products: ISMP urged patients to use reputable pharmacies and watch for signs of counterfeit medications, including spelling errors on packaging, unclear labels and missing instructions.

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