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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

Substitutions Can Be Sticky

When a middle-aged man arrived at a pharmacy to pick up a refill for lactulose (a prescription medicine commonly used as a laxative), he was told that he needed a new prescription from his doctor. There were no refills left on his previous prescription. The pharmacist suggested that the man could use KARO corn syrup as a substitute for lactulose until he visited his doctor for his next check-up.

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Preparing for a Virtual Appointment with Your Doctor

During the coronavirus (COVID-19) pandemic, many doctors have switched from in-person appointments to virtual appointments with their patients using the phone or a computer video call. Virtual appointments, also known as telemedicine, can usually replace in-person visits effectively for consultations and for examinations that do not require close physical contact. They allow doctors to provide clinical services to their patients using electronic communications, without requiring patients to come into the office. Doctors are doing this to maintain physical distancing because COVID-19 can easily be spread from one person to another. Hospitals and clinics are also using telemedicine to communicate with patients and families.

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Look at Your Medicine Before You Take It

Do you carefully read the label on your prescription bottle and look at the tablets before you take a dose of a new or refilled prescription medicine? Well, a 95-year-old woman did, and it helped to prevent a potentially serious mistake. Her doctor had recently increased the dose of her thyroid medicine. When she needed a refill, a staff person at her doctor's office mistakenly told the pharmacist to dispense the lower dose she had taken previously.

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What’s in That Vial?

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