- What is a medication error?
- Who should report medication errors to this site?
- Why should I report a medication error to this site?
- I had a side effect to a drug. Should that be reported as a medication error?
- Should I talk to the organization or health professional that is responsible for an error in my care?
- Will ISMP investigate a complaint on my behalf with an organization or health professional that is responsible for an error in my care?
- Does ISMP believe a health care provider involved in an error should be punished or disciplined for making a error?
Medication errors are preventable mistakes that can happen in labeling, packaging, prescribing, dispensing, and communications when the medication is ordered. Medication errors may involve use of prescription and non-prescription medications, natural health products, imported products and/or devices used to administer medications. Causes include:
- Incomplete patient information, with the health care professional not knowing about allergies and other medications the patient is using
- Miscommunication between physicians, pharmacists and other health care professionals. For example, drug orders can be communicated incorrectly because of poor handwriting
- Name confusion from drug names that look or sound alike
- Confusing drug labeling
- Identical or similar packaging for different doses
- Drug abbreviations that can be misinterpreted
Patients, family members, caregivers or any other individual who may be acting for, or in support of, a patient or client receiving health care, may report medication errors to this site. If you are reporting on behalf of someone you know, you should ask their permission to report the error and be sure that you know all the facts about the incident.
When you submit an incident report to us, we will review it carefully. We look at different things, depending on the type of error you are reporting. Our goal is to prevent errors that have occurred from reoccurring. We also look for problems that can potentially cause harm. Often, we can recommend ways to prevent the same error from happening to someone else. This will make healthcare safer for other
Side effects (unwanted effects that happen when drugs are used under normal conditions) are also known as "adverse drug reactions" and are not considered a medication error. Adverse drug reactions should be reported to The FDA Safety Information and Adverse Event Reporting Program
- Report an adverse drug reaction
Should I talk to the organization or health professional that is responsible for an error in my care?
ISMP encourages you to speak with a health professional if you think an error in your care has occurred. A health professional can take steps to find out if you have been harmed from the mistake and can help you get treatment if necessary. Also, telling a health professional about mistakes in your care will allow them to learn how and why the mistake happened and may prevent the same mistake from happening again. If your mistake happened in hospital and you are not sure who to talk to, many healthcare organizations have "patient representatives" or "patient advocates" who may be able to help with your concern.
Will ISMP investigate a complaint on my behalf with an organization or health professional that is responsible for an error in my care?
ISMP cannot investigate individual complaints about the healthcare organization or health professional that provided your care. ISMP will also not report the error to a professional regulatory authority (an organization responsible for disciplining health professionals). Formal complaints about a particular organization or health professional must be filed through the governing state in which the incident occurred. Contact your State Department of Health or State Licensing Board for more information.
Does ISMP believe a health care provider involved in an error should be punished or disciplined for making a mistake?
Medication errors are rarely the result of one person making an error. There can be many factors that can contribute to an error. Blaming the person who made the mistake without getting to the root of the problem will not prevent the same mistake from being made by someone else. Reviewing incident reports and suggesting safer ways to prescribe, package, dispense or give medication is a better way to prevent harmful errors.
When we review reports, we are looking for the problems that caused the error so that we can recommend ways to make the system safer. This is a much better way to prevent errors than punishing the person who made the mistake.