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

SafeMedicationUse Newsletter

Consumers Can Help Prevent Mistakes with Medication - Check Your Prescription!


Are you wondering how consumers can help prevent mistakes with medications? Here is an example of how ISMP Canada used information reported by a consumer to help prevent medication incidents

A consumer had a prescription for insulin, to be injected every morning and every evening, using an insulin pen. After a morning dose of insulin, the person was found sweating and nearly unconscious. Fortunately, someone recognized the symptoms of low blood sugar and gave the person sugar, followed by more food.

What had happened? The consumer had recently picked up some boxes of insulin at a pharmacy. Most of the boxes were correct, but one box contained a fast-acting brand of insulin. No one had noticed that the wrong box was mixed in with the other boxes. The consumer reported the incident to ISMP Canada, in the hope of preventing the same mistake from happening again.

Insulin products are often stored close together in the pharmacy fridge and ISMP Canada saw that the packages and labels of the two insulin products were very similar. Also, even though the pharmacy used a bar code system to check medications, only one box (which happened to contain the right product) had been scanned. ISMP Canada realized that a mistake like this could happen in any pharmacy. They sent out a safety bulletin to remind other pharmacies of how important it is to check and scan every package when drugs are being dispensed, and to suggest that pharmacies review the way they store insulin in their fridges. They suggested that medications, packages and labels be reviewed with the consumer when prescriptions are picked up, to provide an extra check. ISMP Canada also pointed out the look-alike packaging and labelling of the two insulin products to the manufacturer.

ISMP Canada has a suggestion for consumers--always check your medications carefully when you pick them up at the pharmacy. If you notice any unexplained changes in the medications, the packaging or the directions, be sure to be sure to ask your pharmacist! And please let us know if you experience a medication incident--you can help us prevent others from being harmed by mistakes with medication by reporting medication incidents on our new website,

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