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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

Check Medicine Labels for Potential Food Allergens

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This Oral Syringe Is Not Like the Others

The oral syringes that come with risperidone oral solutions are uniquely labeled and may cause confusion. Risperidone is a medicine used to treat certain mood disorders. Unlike other oral syringes, risperidone oral syringes have a barrel (the part that holds the medicine) that does not have any lines or numbers (markings). Instead, the markings appear on the plunger ( Figure 1). To measure a dose, the plunger must be pulled back until the dose marking aligns with the flange (winged end) of the barrel. Even though these syringes are different than other oral syringes, the instructions do not provide detailed, clearly illustrated information on how to read the markings when measuring a dose. We recently learned about a man who may have taken too much risperidone due to confusion with the dose markings.

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Spotting a Medication Error

Consumers can often spot a medication error by knowing what to expect. This includes knowing what medicine has been prescribed (for example, the name and dose), what the medicine looks like, and what side effects to expect. The following reported error and great catch shows the importance of knowing about the medicine you take.

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Pharmacists Play an Important Role During a Hospital Stay

Hospital pharmacists can answer questions you may have while you are in the hospital.

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