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A component of the Canadian Medication Incident Reporting and Prevention System (CMIRPS).

SafeMedicationUse Newsletter

Consumer "Good Catches" – Part 1: Know What to Expect


For years, consumers have reported medication mistakes to Many of these reports describe a "good catch" — when consumers (or their caregiver, family member, or friend) played a role in spotting a mistake with a medication. In a two-part series of newsletters, details about how these mistakes were caught are shared. Here, in part 1, knowing what to expect is highlighted as an important step in spotting medication mistakes. Part 2 will describe the value of knowing where to look for medication information.

Consumers can often spot a medication error by knowing what to expect. This awareness includes knowing what medication has been prescribed (for example, the name and dose), what the medication looks like, and what effects to watch for. The following is a report from that shows the importance of knowing what to expect:

A consumer was started on a medication to lower blood pressure. The dose was later increased from 4 mg to 8 mg per day. After using the new dose for a few days, the consumer felt overly tired and had low energy. The consumer's blood pressure reading had also dropped by 40 points. Knowing these were side effects of the medication, the consumer read the label on the prescription bottle and noticed that the strength of the medication was 16 mg, not the 8 mg that had been prescribed. has the following suggestions for consumers so that they will "know what to expect":

5 Questions Poster
  • Use the 5 Questions to Ask to help you know what to expect about your medications.
  • Know the medications that have been prescribed for you and why you're taking them.
  • Be familiar with what your medications look like, including the size, shape, colour, and markings of the medication itself and its container.
  • Be aware of the effects of your medication, both good and bad. Knowing this can help you to make sure the medication is working. It can also help you to watch out for side effects, in case something unexpected happens.
  • Do not be afraid to ask questions. Talk to a healthcare provider if anything is not what you expected.

Medication safety bulletins contribute to Global Patient Safety Alerts

This newsletter was developed in collaboration with Best Medicines Coalition and Patients for Patient Safety Canada.

Recommendations are shared with healthcare providers, through the ISMP Canada Safety Bulletin, so that changes can be made together.

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