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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

Available Resources for Safe Acetaminophen Use

Acetaminophen (brand name Tylenol) is well known to consumers as an over-the-counter (OTC) pain reliever and fever reducer. Acetaminophen is an ingredient also found in many OTC and prescription medicines for both adults and children.

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Mark the Bottle!

Out of the corner of your eye, you catch your toddler drinking from his older brother's bottle of liquid medicine. You quickly call the Poison Help (1-800-222-1222). But when they ask you how much your child took, you frantically realize that you don't really know.

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How Your Cell Phone Number and Email Address Can Help Keep You Safe

A patient was accidentally given another patient’s medications at a pharmacy. Later, when a pharmacist realized the mistake, he attempted to reach the patient by phone. However, the patient did not answer. The pharmacist kept trying but did not get through until later that evening. By that time, the patient had already taken another patient’s CELLCEPT (mycophenolate mofetil), a drug that lowers your immunity (it's used in transplant patients to prevent rejection), instead of her new prescription for ZESTRIL (lisinopril) to treat hypertension.

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Double Trouble: Wakix and Lasix Sound Alike

Confusion between the medicines Wakix (pitolisant) and Lasix (furosemide) was reported. Wakix is used to treat adults with narcolepsy (sleep disorder) for excessive daytime sleepiness. Lasix is a diuretic (or “water pill”) which increases the flow of urine to rid the body of excess fluid and salt. Using an online secure messaging system, a man was asking his doctor about a change in his dose of “Wakix” and whether he should get blood tests drawn. The man was also taking Lasix, and the dose had been changed several times over the years. The man had made several spelling errors when typing messages to his doctor. The doctor assumed the man had made a spelling error when typing “Wakix” and was instead talking about Lasix. Further questioning revealed the man actually was asking about Wakix.

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