11/25/2025
🚨 Attention: Community Pharmacists!
💊 ISMP Canada recently received a report of an event involving a mix-up between a hydromorphone and morphine prescription that was transferred between pharmacies.
⚠️ Hydromorphone is 5x more potent than morphine; mix-ups can lead to serious consequences.
To help prevent similar incidents:
✅ Verify prescriptions before transferring to other pharmacies to prevent hand-off errors
✅ Send a copy of the original prescription along with the transfer record, to facilitate technical and clinical verification by the receiving pharmacy.
✅ Perform a clinical check to ensure the medication, indication, and dose are appropriate for the patient
Take the quiz below and learn more:https://ismpcanada.ca/wp-content/uploads/ISMPCSB2004-06.pdf
For more information, review your provincial October 2024 Safety Brief here:�
👉 https://ismpcanada.ca/impact/community-pharmacy-reporting-learning/