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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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Look at Your Medicine Before You Take It

Do you carefully read the label on your prescription bottle and look at the tablets before you take a dose of a new or refilled prescription medicine? Well, a 95-year-old woman did, and it helped to prevent a potentially serious mistake. Her doctor had recently increased the dose of her thyroid medicine. When she needed a refill, a staff person at her doctor's office mistakenly told the pharmacist to dispense the lower dose she had taken previously.

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Seek Immediate Medical Attention for Overdoses

A woman with colon cancer recently received a full dose of fluorouracil at home over 4 days instead of 7 days. Fluorouracil is a drug used to treat cancer by causing fast-growing cancer cells to die. The medicine was given directly into a vein (intravenously) through a portable infusion pump that the woman wore while she was at home. For an unknown reason, the full amount ran in too quickly, leading to an overdose of the medicine. The effects of an overdose are serious and can be fatal. The effects from the medicine infusing too quickly include nausea, vomiting, diarrhea, mouth ulcers, stomach bleeding, and a weakened immune system (making it harder to fight off diseases).

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