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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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Mix-Ups Between Five Different Inhalers that All Include “Ellipta” as Part of Their Brand Names

The name of a unique inhaler device included in five different brand name medicines has led to multiple mix-ups, not only by consumers but by doctors, pharmacists, and nurses as well. In 2013, the global drug company, GlaxoSmithKline, introduced Ellipta, a new type of inhaler device. It is circular in shape, about the size of a hockey puck, and can combine several different medicines together. The company has packaged combinations of one, two, or three of the medicines listed below using this unique inhaler device:

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What to Expect When a Pharmacy Makes a Mistake

Most people realize human error can happen, including when getting a prescription filled at the pharmacy. Although pharmacists do their best, mistakes sometimes happen. Thanks to safer medicine labels and technologies like barcode scanning, mistakes of the past are rapidly declining. The few pharmacy errors that do slip by usually do not cause serious or permanent harm. Still, that’s little consolation to a consumer who is harmed or could have been harmed if a more serious error had happened.

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Most Accidental Poisonings in Children Occur When Medicine is NOT in Its Normal Storage Location

Anyone who takes care of children knows that they have to make their home safe. Whether it's putting up a gate to keep an adventurous child from falling, or covering electrical outlets to keep a curious child away from danger, a safe home is job one. The risk of child poisonings with medicines in the home, however, may not be considered and addressed. 1

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Important Recall: Over-The-Counter (OTC) Artificial Tears Linked to Serious Bacterial Eye Infection

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