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

It May Not Be Safe to Cut a Medicine Patch

Consumers as well as some health professionals may not know that most medicine patches should never be cut before being applied to the skin. Patches are designed to give a constant amount of medicine over a certain period of time, which may range from several hours to a month. The medicine reaches your body by going through the blood vessels under your skin. If the patch is cut, the medicine in each half of the patch might be released too quickly, leading to a serious overdose.

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Chlorhexidine Oral Rinse Needs Improved Packaging

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Provide Two Ways to Identify Yourself When Picking Up a Prescription

Good catch! A mother picking up a prescription for her son was supposed to receive methylphenidate for attention deficit hyperactivity disorder (ADHD). Instead she was given a cardiac drug intended for another patient. The mother noticed the error because the pharmacist mentioned the medicine was for “chest pains.” It turned out that the two patients had the same name. Before leaving the pharmacy with your prescription, always make sure to verify your name and another identifier, such as your date of birth or address. It’s also important for pharmacists to provide drug information when you pick up your prescriptions. After all, that’s how this error was prevented.

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Open Prescription Bag Before You Leave the Pharmacy

It should never happen, but it's not unheard of for another patient's medication to somehow slip into your bag before you pick it up at the pharmacy. Bagging errors can happen when more than one patient's medications are in the pharmacy work field at the same time, often during the prescription packaging process. Pharmacists are well aware of this and most pharmacies do require that staff work on only one patient's medications at a time. Nevertheless, since bags containing prescription medications are not routinely opened at the point-of-sale, if an error does happen it may not be captured before the patient leaves the pharmacy.

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