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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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Parents Staying with Their Hospitalized Child Can Help Detect Some Errors—But May Contribute to Others

Today, parents can often visit and stay with their sick, hospitalized child whenever they want. Many parents take advantage of this and remain with their child as much as possible, getting more involved in their child’s care. For an ill child, this can be comforting and provide an important emotional benefit, which might lead to faster healing as well as long-term behavioral benefits.1 For the parents, this can lead to less stress, anxiety, and sadness. 1

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Providing Unused Medicines at Discharge

Patients sometimes ask to take home left over medicines that were partially used during their hospital stay (e.g., insulin pens, inhalers, eye drops, topical creams or ointments). An example of this involved a diabetic man who was taking the long-acting insulin Lantus (insulin glargine) and also received the short-acting insulin NovoLog (insulin aspart) during his hospitalization.

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Hospital to Home: Know Your Medicines Before You Leave

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Hot Flashes from a Heated Patch

An estrogen patch automatically releases the proper dose of medicine over a defined period of time, usually several days. However, women should know that sunbathing with a patch on may speed up how much medicine enters the body. For example, one woman experienced hot flashes after several days of sunbathing while wearing Climara, a once-a-week estrogen (estradiol) patch.

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