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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

Don't Confuse Depakote with Depakote ER

Depakote (divalproex sodium) ER is a medicine used to treat seizure disorders, migraine headaches, and certain mental illnesses such as bipolar disorder. The "ER" part of the name stands for "extended release," meaning the contents of the medicine are released slowly, not all at once, after you take the medicine. So, Depakote ER should be taken just once a day.

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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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Over-The-Counter Eye Drop and Nasal Spray Danger

Here’s advice about seemingly harmless over-the-counter eye drops, such as Visine and similar products containing the active ingredients tetrahydrozoline, oxymetazoline, or naphazoline. These drugs are quite dangerous if ingested. Severe side effects have been documented after swallowing as little as a half of teaspoonful.

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Make Sure You Get the Right Mix… Ask Questions if Your Medicine Is a Powder

Some medicines, including many prescribed for children, come in a powder form. Water must be added to the powder so the medicine can be easily measured and taken. The ratio of water to powder must be precise, so that the prescribed amount of the final liquid mixture provides the correct dose of medicine per milliliter (mL). It is best for the pharmacist to add water right before the medicine is picked up. Once mixed, the medicine often needs to be refrigerated to stay potent. But if the pharmacist forgets to add the water, or if the wrong amount of water is added at home, a serious dosing error can occur.

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