Marissa Dawson's routine pharmacy visit turned into a months-long nightmare, culminating in a trip to the emergency room. The 35-year-old mother of two was prescribed hydroxyzine, an antihistamine, to manage her chronic eczema. However, she ended up receiving hydralazine, a blood pressure medication, from a Shoppers Drug Mart pharmacy in Moncton, New Brunswick. This mistake had severe consequences, leaving her feeling flushed, dizzy, and struggling to breathe.
Dawson's experience highlights a systemic issue within Canada's medication distribution system. While the country employs a "Swiss cheese model" of medication safety, with various safeguards in place, these measures can fail, leading to potentially devastating consequences. The incident also underscores the importance of pharmacist counselling during medication pickup, a crucial step that was notably absent in Dawson's case.
The issue of medication errors is not isolated to Dawson's experience. Canada dispenses over 800 million prescriptions annually, according to the Canadian Generic Pharmaceutical Association. However, the number of reported errors is likely an underestimation, as only six provinces submit data to the national tracking system, the National Incident Data Repository for Community Pharmacies database. This system recorded over 26,000 medication incidents in 2024, but this figure only accounts for a fraction of the licensed pharmacies in the country.
The consequences of these errors can be life-threatening. The story of Andrew, an eight-year-old boy who died from a medication error in 2016, serves as a stark reminder of the potential impact. His mother, Melissa Sheldrick, has since become a leading advocate for medication safety, emphasizing the need for system-level fixes rather than relying solely on individual healthcare workers.
Sheldrick and pharmacy education researcher Jennifer Lake agree that preventing errors requires more than just increased vigilance. They advocate for clearer drug labelling, separation of drugs with similar names, improved software, and better sharing of patient information across provinces. Additionally, Sheldrick's advocacy for better tracking of errors and "near-misses" has led to the implementation of reporting systems in most provinces, with further progress on the horizon.
In New Brunswick, the College of Pharmacists has introduced a draft policy mandating rest periods for pharmacists to prevent burnout. However, the root cause of errors, as highlighted by Sheldrick and Lake, lies in the complex and increasingly demanding nature of the medication system. The involvement of various healthcare professionals and the growing workloads of pharmacists contribute to the risk of errors.
Dawson's experience has significantly altered her approach to medication pickup. She now double-checks everything to ensure her safety. This incident underscores the importance of patient advocacy and the need for a comprehensive review of medication safety protocols across Canada.
