Incorrect patient

Near miss · Jun 24, 2026 · ← Event log

Complete

Event record

Patient: 19–44 · F (age range + gender only)
Discovered by / prescribed by: Pharmacy technician / —
Stage(s): Rx order entry
Medication(s): Sertraline (DIN 02132702)
Route / associated factors: — · None of the above
Degree of harm: n/a — intercepted before the patient

What happened

Prescription entered on the profile of another patient with the same surname; caught by the technician during basket reconciliation before dispensing.

Immediate actions

Entry corrected; both profiles reviewed for cross-contamination.

Causal analysis & action plan✓

Contributing factors

Miscommunication of drug order

Analysis

Same-surname profiles adjacent in search results; DOB not verified at intake.

Action plan

1) Mandatory second-identifier check at order entry. 2) Enable same-name warning flag in Fillware.

Share learnings with staff✓

Reviewed at huddle; second-identifier check demonstrated.Jun 26, 2026

Sent to NIDR (ISMP Canada)

submitted Jun 25, 2026

The de-identified minimum data set — exactly what leaves the pharmacy:

{
  "event_type": "near_miss",
  "date_of_incident": "2026-06-24",
  "incident_type": "Incorrect patient",
  "discovered_by": "Pharmacy technician",
  "medication_system_stages": [
    "Rx order entry"
  ],
  "medications": [
    {
      "drug_product_name": "Sertraline",
      "din": "02132702"
    }
  ],
  "patient_age_range": "19–44",
  "patient_gender": "F"
}

Stays at the pharmacy

·Time of incident
·Incident description (free text)
·Contributing factors
·Actions taken at the pharmacy
·Prescribed by
·Associated factors
·Route of administration
·Analysis notes, action plans, CQI records
·Who recorded it (login accountability only)

OCP receives aggregate NIDR data only — never pharmacy-identifiable records.