The report highlights implications for pharmacy accuracy and patient safety as a customer questions how the error occurred and whether proper remedies or accountability are in place.

Systemic factors contributing to pharmacy errors include heavier workloads for pharmacists, involvement of multiple providers in prescribing, look-alike drug names, and uneven reporting of medication errors across provinces, with British Columbia slated to begin national reporting in 2026 and Ontario in 2027.

A Moncton woman ended up in the emergency room after Shoppers Drug Mart allegedly dispensed hydralazine, a blood pressure medication, instead of the allergy drug hydroxyzine.

Marissa Dawson, a 35-year-old mother from Moncton, took hydralazine for months instead of hydroxyzine, experiencing dizziness, facial flushing and breathing difficulties, leading to an emergency room visit in April 2025.

CBC News reported that a customer was given the wrong medications for months, specifically blood pressure pills instead of allergy medication, in a Shoppers Drug Mart case.

Experts advocate proactive patient engagement: seek counselling at pickup, verify medications with the pharmacist, and maintain an up-to-date prescription list, with Dawson’s experience prompting extra vigilance.

Experts describe the incident within the “Swiss cheese model” of safety gaps, showing how multiple safeguards can fail; Canada dispenses over 800 million prescriptions annually and reporting to national databases is incomplete.

CBC pieces connect this incident to other near-misses and broader concerns about hospital pharmacist staffing and patient safety.

The article links to related CBC News stories on medical errors, hospital wait times and broader health-system challenges in Canada.

Shoppers Drug Mart acknowledged the mix-up and said it would implement monthly prescription audits for a year, add staff training, and reinforce counselling; Loblaw reviewed the case and introduced patient safety measures and a patient care/quality committee.

Go Public investigates the incident to explain what happened, how it was handled, and what protections or changes are being pursued to prevent recurrence.

Dawson filed a complaint with the New Brunswick College of Pharmacists in May 2025; the college attributed the error to a drug-name mix-up and staff fatigue, and found that no counselling occurred at pickup.