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

SafeMedicationUse Newsletter

What to Expect if the Pharmacy Makes a Mistake


Although pharmacists do their best, mistakes sometimes happen at the pharmacy. It's important to know what to expect your pharmacist to do after a medication mistake is found. received a report from a consumer who picked up a refill of her allergy medication from her pharmacy. The consumer noticed that the new tablets looked different from before and she felt some mild side effects, so she contacted the pharmacy. The pharmacist found that the consumer had been given blood pressure medication intended for someone else with the same name. The pharmacist apologized to the consumer and told her that the pharmacy staff would create a process sure to check everyone's name and address before giving out prescription medications in the future.

If you think there may be a mistake with your prescription, let your pharmacist know.

If there has been a mistake, you should expect the pharmacist to do the following:

ISMP Canada

1. Acknowledge that a mistake has happened and offer an apology.

2. Inform your doctor about what happened (if you have taken any doses of the wrong medication).

3. Send you to your doctor or to the hospital (if you may have been harmed or put at risk by taking the wrong medication).

4. Investigate the cause of the mistake with your medication.

5. Come up with an action plan to avoid similar mistakes in the future.

6. Let you know about the action plan and how it will be put in place.

7. Report the mistake to a third party (e.g., ISMP Canada) so that the learning can help prevent mistakes in other pharmacies.

Consumers, or their families, can also report the mistake to the regulatory college in their province and/or to

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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