Help to Prevent Errors with Prescription Refills

Medication errors can happen when you are getting a refill. You and your pharmacy team can work together to make sure you get the correct medications.

ISMP Canada received a report describing a person who requested a refill of their current medication to manage attention deficit hyperactivity disorder (ADHD). Instead of the correct ADHD medication, they received an ADHD medication that they had used in the past. The person took one dose before noticing the mistake.

• Plan ahead. Request a refill before you run out of the medication. Your pharmacy can tell you how far ahead you can ask for refills.
• Provide the medication name, dose, and quantity (e.g., enough for 1 month) when ordering your refill.
  • If you are calling the pharmacy, it helps to provide the prescription number from the current container.
  • If you are using your pharmacy’s online system, check that the medication and dose on your current container match what you are ordering.
  • If you are making the request in person, it helps to bring in your current container or the outer packaging.
• At pick-up, ask the pharmacy staff to open the bag and check each prescription container with you. This gives both of you a chance to confirm that you’re getting what you expect.
• If you are asked to stop or change the way you take one or more of your medications, ask your prescriber to write down the changes. Share this information with your pharmacy so they can update your pharmacy file.
• Schedule a check-in appointment with your pharmacist if you have questions. This allows the pharmacist to confirm all your current medications and create an updated medication list for you.

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MedError newsletters are reviewed by consumers who are committed to improving medication safety. Learning from consumer reports is shared with health care providers through ISMP Canada publications. This newsletter shares information about safety medication practices, is noncommercial, and is therefore exempt from Canadian anti-spam legislation. *Funding support provided by Health Canada. The views expressed herein do not necessarily represent the views of Health Canada. Mederror is a component of the Canadian Medication Incident Reporting and Learning Prevention System (CMIRPS).