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

SafeMedicationUse Newsletter

Reminder - Check Your Prescription!


Has your pharmacy ever made a mistake with your medicine? If so, you're not alone. Mistakes with medicines can happen even when healthcare professionals have tried their best to prevent them. has received many reports from consumers who received the wrong medicine or the wrong dose of a medicine from a pharmacy.

Here is one example: A consumer had been taking trazodone 25 mg (one half of a 50 mg tablet) at bedtime. One day, when the consumer picked up a new supply of trazodone at the pharmacy, she received white tablets with "100" printed on one side and "Novo" on the other. The consumer knew that her tablets were usually peach in colour, but did not notice the difference until after her pharmacy had closed. Thinking that the appearance of the medicine might have changed because she had been given a different brand of trazodone, she decided to take half of one of the new tablets at bedtime. The next day, she called the pharmacist and was told that a mistake had been made. The consumer returned the medicine to the pharmacy and was given the correct strength of trazodone. The person who reported the mistake to stated that the white tablets contained 100 mg of trazodone. Fortunately, the consumer experienced no harm from taking one incorrect dose.

Why do mistakes like this happen? One reason is that preparing medicines involves people, and people in every profession sometimes make mistakes. Healthcare professionals are trained to use safe practices when they prepare medicines, but no one can be perfect all the time. In this case, it is not known how the mistake happened, but problems in the work environment or problems with the packaging or labelling of products may increase the chances of a mistake. For example, it can be easier to make a mistake if the labels or names of different products look alike. Problems like these are sometimes called "system problems".

Healthcare professionals often use double-checks as a way of finding mistakes before they reach patients. Consumers can do this too! Be sure to double-check your medicine before you leave the pharmacy. The list of questions in the text box on the next page may help you to notice things that were missed during the preparation of your medicine. If anything looks different from what you were expecting, speak with a pharmacy staff member. Do not take any doses of the medicine until your concerns have been addressed. If you notice a mistake after the pharmacy has closed, call your local poison information centre or health information service for advice.

You can support ISMP Canada's efforts to prevent harmful medication errors. If you experience or make a mistake with your medicines, even a mistake that caused no harm, visit and tell us about it. Even reports of things that might cause a mistake, such as a confusing label, can be very useful. ISMP Canada will review your report and look for ways to make the medication system safer. Consumer reports are already making a difference!

Check Your Prescription! recommends that consumers check their prescriptions before leaving the pharmacy. Ideally, this should be done while the pharmacist is reviewing your medicines with you. Here are some things to ask yourself when checking your medicine:

  • Is my name on the prescription label?
  • Is this the medicine that my doctor prescribed for me?
  • Are the strength, the dose and the dosage form what I was expecting?
  • If I've had this medicine before, does the medicine or the package look the same as it did the last time? Do the identifying markings on tablets and capsules match what I expect to see?
  • Are the directions for use the same as what I expected? Do I understand the directions?
  • Have I been given the right amount of the medicine?
  • If there is more than one box or container of the same medicine, are all of the packages the same?
  • Have I been given all of the medicines that my doctor prescribed (or all of the refills that I requested)?
  • Have I been given information about the medicine, how to take it and any precautions?

Being aware of a few key things to check can help consumers to catch mistakes before they cause harm. If the answer to any of the above questions is "no", speak with a pharmacy staff member right away!

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