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

SafeMedicationUse Newsletter

Mistaken Identity – A Recurring Problem


Ever wonder why it is important that pharmacy staff ask for your birthdate, address or other identification every time you pick up a prescription? It's a way to help make sure that medication is handed to the right person.

twins illustration continues to receive reports about consumers accidentally receiving another person's medication. In one example, a consumer went to the pharmacy to pick up her medication. But the medication had mistakenly been given to someone else with the same name. The person who received the medication by mistake now had the consumer's information, such as her prescription history.

In another example, twins were confused for one another. When one of the twins was dropping off a prescription at the pharmacy, he was told that his "other" prescription was ready. However, that "other" prescription actually belonged to his twin brother. has the following advice for consumers to make sure that the prescriptions you receive actually belong to you:

  • When you go to a pharmacy, hospital, or other healthcare setting always identify yourself using your full name and at least one other piece of information. The additional information can be your date of birth, your home address, or your health card number.
  • Before you accept a medication from the pharmacy, check for your name and address on the bag.
  • If you are a twin or other multiple, let your healthcare providers know about the possible confusion with your siblings. Having a similar physical appearance, similar names, and the same birthdate, and possibly also sharing the same address, all increase the risk for a mix-up.
  • Make sure your healthcare providers are aware of your "preferred" name. Ask to include this name in your file, along with your full name as it appears on government-issued identification.

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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