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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 a Product Called WartSTICK with Lip Balm!

Many people are familiar with over-the-counter wart treatments. They're typically liquid based or are packaged in an aerosol container with a special application tip. But did you know there is also a wart remover that uses a dry formulation in the form of a stick? Within the last year a company called Balassa Laboratories has repackaged an old formula of a solid stick wart remover (previously packaged under the name PediFix). The newly packaged product, called WartSTICK, is now available at popular chain drugstores such as CVS, Rite Aid and Walgreens on-line. Our concern? It looks identical to a container of lip balm. The active ingredient in WartSTICK is salicylic acid, which should NEVER come in contact with the lips or mucous membranes inside your mouth.

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Understanding the Risks of Clindamycin: A Cautionary Tale for Dental Patients

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Angeliq — It’s Not a Birth Control Pill!

It's important for women to be aware of an issue with the prescription product Angeliq, a hormone-based medicine used to relieve the symptoms of menopause. Unfortunately, we're aware of errors where it's been dispensed or prescribed improperly as an oral contraceptive.

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Ear Wax Removal Drops Looks Like Eye Drops

A woman accidentally put ear wax removal drops (carbamide peroxide 6.5%) into her eye. This caused irritation and redness that persisted after rinsing her eye with water for 15 minutes. The bottle of ear wax removal drops (Figure 1) looks like a container used for eye drops. A warning that the drops are for the ears only is not on the front of the bottle (and carton) label. On the back of the carton, it says, “When using this product, do not get into eyes” in the Drug Facts table, but it does not stand out. This is mentioned on the side of the bottle, but the warning is buried in the middle of a paragraph in very small print.

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