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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 Mix Up Concentrated “Ibuprofen Infant Drops” with “Children’s Ibuprofen”

Ibuprofen is s an over-the-counter (OTC) medicine that parents might give their child to relieve minor aches and pains or reduce a fever. For children, it is available in chewable tablets (100 mg each) and an oral suspension (liquid). But parents may not be aware that there are two different concentrations of the oral suspension. Ibuprofen for infants contains 50 mg per 1.25 mL (40 mg per mL) and is often called “infant drops.” This medicine is for 6- to 23-month-old babies who weigh 12 to 23 pounds (5.5 to 10.5 kilograms [kg]). Babies may not be able to swallow a large amount of medicine. So, ibuprofen for infants is more concentrated than ibuprofen for children.

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Use Your Pre-Admission Testing Appointment to Prevent Errors

If you are scheduled in advance for surgery or a procedure, you will need to go to the hospital for a pre-admission testing appointment. You might need blood tests, a physical exam, and instructions about what to do before the procedure. This is a great time to go over your current list of medicines with the nurse or doctor.

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Liquid in Fish Oil Capsules Interacts with Foam Cups

A nurse caring for a patient who was unable to swallow Lovaza (omega-3 fatty acids), punched holes in the large, soft gelatin capsule, squeezed the oily yellow liquid contents into a disposable foam (Styrofoam) cup, and diluted it with cranberry juice. Later, as the patient raised the cup to drink the juice, the cup began to leak.

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Mix-Ups Between Doses of Children and Adult Vaccines

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