Incorrect drug

Medication incident · Jun 4, 2026 · ← Event log

Complete

Event record

Patient: 45–64 · F (age range + gender only)
Discovered by / prescribed by: Pharmacist / Physician
Stage(s): Preparation / dispensing
Medication(s): Hydralazine, Hydroxyzine
Route / associated factors: oral · None of the above
Degree of harm: none

What happened

Look-alike selection error between two products stored adjacently; intercepted at the final check but after the vial was filled and labelled.

Immediate actions

Correct product dispensed; stock physically separated with shelf talkers.

Causal analysis & action plan✓

Contributing factors

Look-alike / sound-alike drugs · Interruptions / high volume / workload

Analysis

Adjacent storage of look-alike stock plus a lunchtime volume peak.

Action plan

1) Permanent shelf separation with tall-man lettering labels. 2) Add both products to the high-alert double-check list.

Share learnings with staff✓

Shared via staff memo and huddle.Jun 6, 2026

Sent to NIDR (ISMP Canada)

submitted Jun 5, 2026

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

{
  "event_type": "incident",
  "date_of_incident": "2026-06-04",
  "incident_type": "Incorrect drug",
  "discovered_by": "Pharmacist",
  "medication_system_stages": [
    "Preparation / dispensing"
  ],
  "medications": [
    {
      "drug_product_name": "Hydralazine",
      "din": null
    },
    {
      "drug_product_name": "Hydroxyzine",
      "din": null
    }
  ],
  "patient_age_range": "45–64",
  "patient_gender": "F",
  "degree_of_harm": "none"
}

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.