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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

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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Do Not Take Medicine in the Dark!

A man was awakened by a toothache in the middle of the night. Without turning on the lights, he pulled out and applied what he thought was a spray of pain reliever for his toothache. Afterwards, he did not rinse his mouth. In the daylight of the morning, he realized he had actually used Lamisil AT Pump Spray in his mouth.

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Liquid in Fish Oil Capsules Interacts with Foam Cups

A nurse caring for a patient who was unable to swallow Lovaza (omega-3 fatty acids), punched holes in the large, soft gelatin capsule, squeezed the oily yellow liquid contents into a disposable foam (Styrofoam) cup, and diluted it with cranberry juice. Later, as the patient raised the cup to drink the juice, the cup began to leak.

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The Great American Smokeout

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