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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

Preventing Dangerous Sleep Medication Mix-Ups

Many of us have hectic schedules and we sometimes struggle to get a good night’s sleep. In fact, it is estimated that 40 million Americans suffer from chronic insomnia (sleeplessness) and an additional 20 million experience occasional insomnia. Therefore, some people turn to sleep medicines to help treat the problem.

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Avoid Sore Eyes

Are you using eye drops to help relieve your sore eyes? If you overuse eye drops that contain decongestants (ingredients that shrink swollen blood vessels) such as naphazoline, tetrahydrozoline, or phenylephrine, it could lead to conjunctivitis--swollen, red, sore eyes with a liquid discharge. It could take weeks for this condition to clear up. Use your eye drops as directed on the label, or your red eyes may actually worsen.

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Fentanyl Patches Can Be Deadly to Children

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Make Sure You Get the Right Mix… Ask Questions if Your Medicine Is a Powder

Some medicines, including many prescribed for children, come in a powder form. Water must be added to the powder so the medicine can be easily measured and taken. The ratio of water to powder must be precise, so that the prescribed amount of the final liquid mixture provides the correct dose of medicine per milliliter (mL). It is best for the pharmacist to add water right before the medicine is picked up. Once mixed, the medicine often needs to be refrigerated to stay potent. But if the pharmacist forgets to add the water, or if the wrong amount of water is added at home, a serious dosing error can occur.

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