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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

Nicotine Lozenges Mistaken as Candy Mints

In February, the Chicago Sun Times reported that 16 elementary school children had been taken to local hospitals with a sudden illness. The children were 9- and 10-year olds who began vomiting after eating “mints” given to them by another classmate. It was later found that these “mints” were actually nicotine -replacement lozenges, called NiQuitin Minis ( Figure 1 on page 3). ( NiQuitin is a product from the United Kingdom that is sold online; however, the Nicorette brand made in the US has a similar product.) The classmate found the lozenges at home and brought them to school to share.

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Accidental Poisonings of Babies - Birth to 6 Months: How They Happen and What You Can Do to Prevent Them

Medicines are a leading cause of accidental poisonings in young children. When we think about this, older babies and toddlers who can scoot, crawl, walk, and/or climb come to mind. Older babies and toddlers are curious and explore their world by “mouthing” the items they find. If they see something that looks interesting, they often reach for it or climb to it. Therefore, it is important to keep medicines and other potentially toxic products up and away and out of the sight and reach of children.

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Tricky Dosing for an Important COVID-19 Medicine

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More Than TWO Could Be a Clue!

A consumer recently contacted us about a medication error that occurred with her father's prescription. The prescription was for a highly concentrated form of liquid morphine known as Roxanol.

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