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

SafeMedicationUse Newsletter

Does This Medicine Belong to Me?


Two years ago, alerted consumers to US media reports about a woman who was accidently given someone else's medicine by her pharmacy. Read more. It appears the mistake happened because of a mix-up between similar patient names. Since then, has received two reports from consumers who were each given a prescription labelled with someone else's name.

Occasionally, things go wrong when medicines are being prepared in the pharmacy. For example, one person's medicine may be placed into a bag that is labelled with someone else's name. A label prepared for a prescription may be mistakenly placed on a vial containing another person's medicine. A person may be handed another person's bag when picking up a prescription at the pharmacy. Most errors are noticed during the pharmacy checking process. However, if they are missed, mistakes like these could result in someone receiving a medicine that was intended for someone else. Taking a medicine that was intended for someone else and not getting your own medicine could cause harm.

You can help to make sure that the medicine you receive at the pharmacy is intended for you by remembering the following tips.

  • When requesting or picking up your prescription or refill at the pharmacy, always provide at least 2 pieces of information that identify you. For example, in addition to your name, also give your address or date of birth.
  • Check your medicine before leaving the pharmacy counter. Make sure that the patient name on the prescription label is yours. Check that the medicine is the one your doctor or other healthcare provider prescribed for you.
  • Be familiar with the names of your medicines, why you take them, and how you take them. When you pick up a prescription or refill, ask your pharmacist to explain what the medicine is used for and to review the instructions on the label with you. If any of the information is different from what you were expecting, tell the pharmacist. Make sure that your concerns have been addressed before you take the medicine.

Following these simple steps can help to ensure that the prescription you pick up from the pharmacy is your medicine, not someone else's.

For information on preventing "wrong person" mistakes with medicines while in hospital, see the SafeMedicationUse newsletter Let People Know Who You Are.

Reminder: Similar Medicine Names Can Lead to Errors! recently received a report about an elderly consumer who received bisoprolol (a medicine used to treat high blood pressure) instead of bisacodyl (a laxative) from a community pharmacy. The mistake was not noticed, and the person took the bisoprolol instead of bisacodyl for 2 weeks. Eventually, he was admitted to hospital with low blood pressure. A family member brought a list of medicines to the hospital, and the right medicines were given during the hospital stay. However, no one realized that the consumer had been taking bisoprolol at home instead of bisacodyl. The problem wasn’t noticed until he returned home and began taking the bisoprolol again. A family member eventually noticed the mistake. reminds consumers to check prescriptions carefully when picking them up from the pharmacy. ISMP Canada is also reminding healthcare professionals about the possibility of harmful mix-ups between bisoprolol and bisacodyl.

More information on preventing mix-ups with medicines that have similar names.

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