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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Once a Day Is Not the Way if Once a Week Is Enough

The story: Methotrexate is a cancer medicine. More recently, doctors have used it to treat other conditions like rheumatoid arthritis and psoriasis. It works well for these other conditions if you take the medicine just once or twice a week, and in smaller doses. But if you take it every day by accident, you could be harmed. Sadly, some people have even died.

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Possible Risk of Injury Following EpiPen Jr Injection

If you keep an EpiPen Jr (epinephrine) auto-injector on hand in case a child has a severe allergic reaction, you need to know about the risk of cutting a child while the needle is under the skin if he or she moves during the injection. An EpiPen Jr auto-injector is a disposable automatic injection device filled with 1 dose of epinephrine. When the orange tip is pressed against a child's outer thigh until it "clicks" and then held there for 10 seconds, the dose is automatically delivered. Prompt treatment of severe allergic reactions in the home and community can be lifesaving and has resulted in better survival rates and less long-term effects. Most often, auto-injectors are used successfully without complications. But two children recently sustained cuts on their legs when using the EpiPen Jr.

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Picking Up the Right Patient's Prescriptions

A pharmacy technician in a chain retail pharmacy issued the wrong medicines to a patient. The pharmacy uses a bin system for prescriptions awaiting pick-up and the technician accidentally selected the prescription in the bin next to the correct one. The first name of the two patients was exactly the same.

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Replace Bottle Adapter with Childproof Cap after Using Liquid Medicine

Liquid medicines, especially those required for small children and pets, are often measured using oral syringes. Sometimes, there is a device that comes with the syringe called an adapter. This allows the oral syringe to directly attach to the bottle, eliminating the step of pouring the liquid into a cup for withdrawal by an oral syringe.Using a syringe adapter is a convenient way to accurately measure and administer liquids. However, depending on the actual product, parents should be aware they are not always childproof.

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