Tell Us About the Error

 

Thank you for reporting your error or medication safety concern to ISMP. Please answer the questions as completely and accurately as possible. Your answers will help us to better understand the type of errors that are happening, where and why they are happening, and how to help those people being affected.


Required Information:

Please describe what happened or what could happen due to your safety concern or error. Please review such topics as What Should be Reported, Who Should Report and other links in this section.

  1. Describe the error or adverse drug reaction. What went wrong?
  2. Was this an actual medication error that happened to you or a loved one, or are you expressing concern about a potential error that was discovered before it reached the patient?
  3. Type of practice site (hospital, private office, retail pharmacy, long-term care facility, etc).
  4. The name of all drugs and/or medical products related to the error.
  5. If known, the dosage form (capsule, tablet, injection, etc), concentration or strength, etc.

ERROR DESCRIPTION
Be sure to include the names of all drugs involved. *Required

Please include any product photographs, scans of doctor's prescriptions, associated records, etc. that might help us understand your report. Be sure not to include any personally identifiable information such as your name, social security number, etc.

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Approximate date of the error or event or discovery of the medication safety concern: *Required
How was the error/concern discovered? *Required
What was the final outcome to the person/patient involved in the error?
If an error or event happened, what was the age of the person affected at the time of the error/event?
What do you think should have been done to avoid this type of mistake or your safety concern?
Is this the first time you have reported an error, event, or concern on this website?


If an error or event happened...
Optional Information
Did any of the following happen to the person because of the error (check all that apply):









Had you, the person involved in the error, or their caregiver been provided with specific instructions regarding how to take the medicine?

If yes, who provided this information?



If yes, how were the instructions administered?
If yes, were the instructions easy to understand?

Who discovered the event?
Were you or the person affected by the error or bad reaction told about it by a healthcare provider?

Did you or the person affected by the error receive an apology from the healthcare provider(s) for the error?

Optional Personal InformationAll communications are strictly confidential. ISMP will not disclose your identity to any individuals or outside organizations without your expressed permission. However, we need to be able to communicate with you in case we have follow-up questions. Also, you will only receive an email confirmation of this report if you provide an email address below. If you do not provide any identifying information, please print the final report page for your records.

Person Submitting Report:
Important!
Our organization shares information with the FDA, in confidence, when we receive a report. Both organizations (ISMP, FDA) utilize these reports to identify and address drug-related problems by working with drug manufacturers, scientists and others. Please indicate which of the following organizations we may not share your report with (your information will be handled 100% securely and confidentially):




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