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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

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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Summer Danger with St. John's Wort

A young woman developed temporary nerve damage 4 weeks after taking 500 mg of St. John's wort daily for mild depression. She began to feel pain on skin exposed to the sun. Her doctor told her to stop taking the herb. She did, and her symptoms slowly went away.

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A Documented Allergy Overlooked

A doctor prescribed Donnatal (hyoscyamine, atropine, scopolamine, and phenobarbital) for a man who was allergic to one of its ingredients, phenobarbital. Donnatal is used to relax the muscles in the bladder and intestines and to reduce stomach acid. The community pharmacy’s computer system issued a warning about the allergy, but the pharmacist missed seeing the message while entering the prescription into the computer. The doctor also overlooked the allergy even though it was documented in the patient’s chart. The error was discovered by the man while reading the pharmacy provided consumer medication information leaflet, which listed phenobarbital as one of the ingredients. The man did not take the Donnatal.

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Delivery Errors Can Occur

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