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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

Baby Food or Drug Disposal Pouch?

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Measurement Mishaps with Liquid Medicines

Unlike medicines for adults, medicines for babies and young children often come in a liquid form. Thus, parents and caregivers must measure the correct amount of liquid medicine before giving each dose to their child. Many over-the-counter (OTC) liquid medicines come with a plastic dosing cup, oral syringe, or dropper to help measure a dose. A pharmacist may provide a dosing cup or oral syringe with liquid prescription medicines. However, a study published in October 20161 shows that parents often struggle with measuring the exact dose of liquid medicine and make errors frequently.

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Open Prescription Bag Before You Leave the Pharmacy

It should never happen, but it's not unheard of for another patient's medication to somehow slip into your bag before you pick it up at the pharmacy. Bagging errors can happen when more than one patient's medications are in the pharmacy work field at the same time, often during the prescription packaging process. Pharmacists are well aware of this and most pharmacies do require that staff work on only one patient's medications at a time. Nevertheless, since bags containing prescription medications are not routinely opened at the point-of-sale, if an error does happen it may not be captured before the patient leaves the pharmacy.

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Designer Pain Creams and Ointments Are Profitable for Compounding Pharmacies but Risky for Patients and Children

Certain pharmacies, known as compounding pharmacies, can mix different ingredients together to produce a patient-specific product. Popular compounded products include pain creams and ointments that contain a combination of multiple potent medications. Many include drugs that can cause central nervous system depression or cardiac effects that result in slow breathing, a low heart rate or irregular beat, and drowsiness or a loss of consciousness. These drugs may include:

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