Incorrect label

Medication incident · May 5, 2026 · ← Event log

Complete

Event record

Patient: 65–84 · M (age range + gender only)
Discovered by / prescribed by: Patient / Physician
Stage(s): Preparation / dispensing
Medication(s): Metformin (DIN 02099233)
Route / associated factors: oral · Compliance packaging
Degree of harm: none

What happened

Label carried the previous directions after a dose change; the patient noticed the mismatch against the blister pack and called before taking any doses.

Immediate actions

Corrected label issued; blister pack re-checked; dose-change re-labelling step reviewed.

Causal analysis & action plan✓

Contributing factors

Process deviation

Analysis

Dose-change orders bypassed the re-label check when filled from the compliance-pack queue.

Action plan

1) Add a forced re-label step to the compliance-pack queue on any direction change. 2) Verify at next pack cycle.

Share learnings with staff✓

Reviewed at morning huddle; queue change demonstrated to all staff.May 7, 2026

Sent to NIDR (ISMP Canada)

submitted May 6, 2026

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

{
  "event_type": "incident",
  "date_of_incident": "2026-05-05",
  "incident_type": "Incorrect label",
  "discovered_by": "Patient",
  "medication_system_stages": [
    "Preparation / dispensing"
  ],
  "medications": [
    {
      "drug_product_name": "Metformin",
      "din": "02099233"
    }
  ],
  "patient_age_range": "65–84",
  "patient_gender": "M",
  "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.