Wednesday, 05 January 2011 17:00

What Do We Do With Your Report

At ISMP, we review incident reports submitted by consumers and health professionals and look for ways to prevent harmful errors. For example, we may approach a manufacturer to suggest that the label of a product be changed, we may suggest safer ways for health professionals to handle medication, or we may remind consumers of things they can do to avoid making mistakes with medication.

ISMP will:

  • review your report
  • look for system problems that could cause errors to happen
  • prepare recommendations that are designed to prevent mistakes with medication
  • send recommendations about medication safety to health professionals and consumers
  • notify the US Food and Drug Administration's MedWatch Program and the manufacturer if a product issue
  • advocate throughout the healthcare system to promote changes to improve medication safety
  • provide consumer-focused information and tips about medication safety on the website

ISMP will not:

  • investigate a complaint on your behalf with an organization or health professional that is responsible for an error in care
  • investigate the actions of individual practitioners
  • report (for disciplinary purposes) the incident to professional authorities responsible for regulating the practice of health professionals
  • release or publish any information that could identify the reporter of an incident, a patient, a health professional or an organization involved in an incident


Wednesday, 05 January 2011 16:59

Who Should Report an Error?

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 incidents to this site. If you are reporting on behalf of someone you know, you should ask their permission to report the incident and be sure that you know all the facts about the incident.


Wednesday, 22 December 2010 19:36

What Should Be Reported


We're interested in learning about medication errors, near misses, hazardous situations or bad drug reactions experienced by you or a loved one. These problems may be related to:

  • Issues with prescriptions
  • Pharmacy or hospital procedures, staff, and systems
  • Inadequate medication instructions
  • Poor communication of information from a health care professional
  • Medicine labels and packaging
  • Names of medications
  • The preparation and/or mixing of medications
  • The way in which you order medication (Internet, telephone, mail, etc.)
  • Unexpected reactions to a drug


Medication errors, near misses, or hazardous situations that should be reported include, as well as bad reactions, but are not limited to:

  • Receiving the wrong drug, strength, or dose of medication that was ordered for you
  • Being prescribed a drug to which you were allergic
  • Having an unexpected reaction to a drug because you were taking another drug or food that shouldn't be eaten while taking the drug
  • Taking a drug incorrectly because you did not understand how or when to take it
  • Developing an already known but unexpected side effect because the provider did not give clear or full instructions on how to properly take the drug. For example, if you got an upset stomach because you were not told to drink a full glass of water when taking your medicine or getting sunburned because you were not counseled that the drug requires you to stay out of sunlight.
  • A problem with equipment used to give the medication such as with IV (intravenous) pumps, PCA (patient controlled analgesic) pumps, and insulin pens, etc.


Tuesday, 21 December 2010 18:49

Why Report an Error?

Although most medication incidents don’t cause harm, some have caused serious harm and even death. Often, mistakes with medication are caused by underlying problems in the system. For example, just as confusing road signs can cause accidents on the road, problems such as look-alike labels, confusing equipment and poor handwriting can lead to mistakes in health care.

When incidents are reported and reviewed, problems that could increase the chance of an error happening can often be found and corrected. This is a much better way to prevent errors than punishing the person who made the mistake. 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. By reviewing incident reports and suggesting safer ways to prescribe, package, dispense or give medication, we can help prevent harmful errors.

You may use the online form to submit a medication incident report to ISMP. More information about reporting medication incidents is available at What Should be Reported, Who Should Report, Why Report, and Other Ways to Report.

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