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Reporting a Medication Error

What Do We Do With Your Report?

At ISMP, we review incident reports submitted by consumers and healthcare 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 healthcare professionals to handle medications, or we may remind consumers of things they can do to avoid making mistakes with medications.

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 healthcare professionals and consumers
  • Notify the manufacturer if it is 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 ConsumerMedSafety.org website
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ISMP will not:

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

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More Safety Articles

Poisoning Amongst the Senior Population

Reports show that seniors are at an increased risk for poisoning. Some experts estimate that half of all seniors mismanage at least one of their medications and that seniors are twice as likely as other patients to present to the emergency room as a result of drug safety issues, such as, confusion over multiple medications, skipped doses, or variances from recommended doses.

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Beware of Desiccants in Blister Cards

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Check Your Inhaler Before Use!

After using his albuterol inhaler, an asthmatic man began to cough uncontrollably. Instead of the medicine making it easier for him to breathe, he felt like something was stuck in his breathing passages. An X-ray at a clinic confirmed that there was a coin in his windpipe and a dime that had to be removed through a tube inserted down his throat.

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Please, Please, Open the Bag!

One of the most frequent errors in the pharmacy is giving a correctly filled prescription medicine to the wrong customer. Recently, we received another report of this type of error. A parent of a 16-year-old teen picked up what was supposed to be an antibiotic to treat his acne, minocycline. The next month, when looking at the prescription label to call in a refill of the medicine, the teen’s mother realized the prescription medicine was for a different person, and the medicine dispensed was not minocycline. Instead, Xarelto (rivaroxaban), a medicine used to prevent blood clots after surgery or in people at risk of having a stroke, was listed on the label. Fortunately, the teen was not injured. However, the risk of bleeding from taking Xarelto in error for a month is certainly significant.

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