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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