Your Health

Medication mix-ups a cause for concern among seniors

Senior woman with a pill bottle.
Photo of Dr. Harold Nyhof LAURIE THOMPSON
Winnipeg Regional Health Authority
Published Friday, October 28, 2016

If there is one thing I've learned while working as a patient safety champion over the last 12 years it is simply this: medication mix-ups happen far more often than people realize.

I was reminded of that lesson again recently as I was reviewing some material in preparation for Canadian Patient Safety Week, which ran last October.
It involved a 72-year-old woman on home care who was finding it difficult to live her life to the fullest because she experienced extreme dizzy spells when standing or walking.

Eventually, one of her home care workers decided to sit down with the woman and go through all of her medications, a process known as medication reconciliation.

As it turned out, Mrs. A's medications were the source of her problem. Somewhere along the line, she had been prescribed multiple blood pressure medications and it was the combination of different pills that was actually at the root of her deteriorating health.

After consulting with a doctor, Mrs. A's medications were changed, her blood pressure became stable and her health improved to the point that she no longer needed home nursing care. 

Yes, medication mix-ups happen, and they happen often. 

Consider these numbers:

An estimated 40 to 50 per cent of patients in hospital and 40 per cent of patients discharged from hospital experience potential medication errors that could lead to health issues. In Manitoba, it is estimated that medication-related incidents are the third leading cause of all harmful patient incidents. These injuries can result in emergency department visits, admission to hospital, and death.

Seniors are particularly vulnerable to medication mix-ups.

In 2008, the Canadian Institute of Health Information found that two-thirds of seniors were on five or more drugs, and 21 per cent of these took at least 10 drugs. It's easy to see how the average person can lose track of what they are taking and how often they are taking it.

Fortunately, there are ways to reduce the risk of harm from medication mix-ups.
One is to ask questions. The Institute for Safe Medication Practices (Canada) suggests five important questions to ask your doctor, nurse and pharmacist about your medications. They are:

  1. What has changed about your prescription and why?
  2. What medication do I need to continue taking? Why?
  3. What is the correct way to take the medication? How long?
  4. How do I know that the medication is working? What are the side-effects?
  5. What follow-up do I need?

Seniors should ask these questions every time they are prescribed a new medication, given a medication, and when they buy medications without a prescription (over the counter medications). They should also ask questions in the hospital, at the pharmacy, and with the nurse or doctor during health-care appointments.

A second way to reduce the risk of a potential mix-up is to review medications at transition points, such as when moving into a personal care home, at discharge from hospital, picking up new prescriptions from the pharmacy, and when receiving home care services.

Health experts say this action alone would significantly reduce the potential for harm from medication incidents. Seniors should work with their doctor, nurse or pharmacist to make sure that nothing is missed and that all differences between what you are taking compared to written instructions is talked about.

The health-care system does its best to ensure that the right medication information is communicated each time a patient moves from one health-care setting to another. However, when medication mix-ups occur, it is most often from miscommunication or lack of communication.

To assist seniors with both of these important actions, the Manitoba Institute of Patient Safety has created a special card than can be used to list all of your prescription and over the counter medications, including vitamins, minerals and herbal/natural products.

The It's Safe to Ask medication card can be obtained by visiting

Print the card and fold it into a handy wallet size. Let family members, friends and loved ones know that you have the card. Keep it up-to-date and share it with your doctor, nurse and pharmacist.

For more information about patient safety, visit:

Laurie Thompson is the Executive Director of the Manitoba Institute for Patient Safety. This column was originally published in the Winnipeg Free Press on Friday, Oct. 28, 2016.

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Click here to read more about the WRHA's efforts towards reconciliation

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