When Jean Marris of Mississauga, Ont., filled her prescription for her medication last Sunday, she was alarmed when she returned home to find dozens of extra pills.
“I just was absolutely shocked at opening it and seeing a dozen more pills than I’ve ever, ever taken,” Marris, 60, told Global News. “Eight pills for the morning. More in the afternoon and more in the evening. I panicked thinking my doctor has prescribed all these to me? I have a very good relationship with my [doctor] and I just thought, yikes this is not right.”
Marris, who normally takes two pills in the morning for blood pressure and another medical condition, realized the pharmacist dispensed the wrong medication intended for another woman with the same first name. The package also included other personal and medical information.
She went back to the Shoppers Drug Mart to inform the owner of the mistake, but was told he was away on vacation. Instead, she returned the medication to two pharmacists who apologized “profusely.”
“I was nearly ready to cry because I just said ‘this [is] just an awful mistake’ and this could have deadly consequences,” Marris said. “How could I get two huge blister packs of so many pills which were unknown to me? There has to be a better system to label the bag or some kind of reference check.”
Experts say the consequences of dispensing the wrong medication can have dangerous, even deadly consequences.
“They are obviously very potentially dangerous in situations where people get the wrong medication, or the wrong dose of the medication, or the wrong instruction can lead to patient harm,” said Ross Baker, professor at the University of Toronto’s Institute of Health Policy, Management and Evaluation.
Global News has previously reported on the story of Andrew Sheldrick, an eight-year-old boy from Mississauga who died last March after ingesting the wrong medication that was given to him by a pharmacy. His mother is now calling for mandatory prescription-error reporting across the country.
Pharmacists in Canada dispense more than 600 million prescriptions annually, yet there is no national tracking system for pharmacists who make mistakes. Currently, Nova Scotia is the only province in Canada that has a mandatory system for tracking pharmacy errors. Dubbed SafetyNET-RX, the program requires pharmacists to report all errors to The Institute for Safe Medication Practices (ISMP) Canada.
“If I’m a patient and I receive the wrong medication it would be very upsetting,” said Certina Ho, project manager at ISMP. “Depending on the medication there may be some harm there may not be.”
A report from ISMP’s Community Pharmacy Incident Reporting program found that between 2010 and June 2016 there have been 103,258 incidents reported from Nova Scotia, Saskatchewan and New Brunswick, including 887 incidents that contributed to harm and two cases that may have resulted in deaths.
“The key here is to figure how do we design systems that are going to reduce the likelihood of error, but probably never eliminating it,” said Baker. “Ask questions, and double check. Don’t assume that people are doing the right thing. Our [health care] system is under a lot of stress right now and people are working very hard to keep up with the demands, and it sometimes means that mistakes happen.”
A spokesperson for Shoppers Drug Mart said it is investigating the incident.
“This is a serious matter and we apologize for the error on behalf of the pharmacy team,” said Tammy Smitham, vice-president of communications for Loblaw Companies Limited & Shoppers Drug Mart, in a statement. “This type of situation is very rare. We are investigating this incident and are following up with the pharmacy team directly.”
Marris said she hopes her story draws attention to the issue of pharmacy dispensing errors and wants more safeguards in place.
“What if I had taken one of those pills? It’s just careless,” she said.
ISMP advises all pharmacies to use at least two patient identifiers — such as name and address — to prevent mistakes. Pharmacy staff should also open the bag and review all medications with the patient.
“Mistakes do happen, but there are ways we can prevent them from happening in the future,” Ho said. More information from ISMP about the “5 Questions to Ask about your Medications” can be found here.
Ontario Health Minister Eric Hoskins and the Ontario College of Pharmacists both declined to be interviewed for this story.
In a statement Minister Hoskins said he directed the College of Pharmacists to identify additional steps to address the concerns around medication errors and look at the Nova Scotia model.
“I am happy to hear that the College has taken swift action, establishing a Task Force to look at this issue with a plan to be approved by March,” Hoskins said.
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