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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

Confusion with Use "As Directed” Instructions

Sometimes, your doctor may write or send your prescription to the pharmacy with instructions to take the medicine “as directed.” In these cases, you must remember what the doctor has told you about how to take the medicine correctly. The label on the prescription container will not help you remember because the directions will simply say, “Use as directed.”

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An Unexpected Painful Breath

Do you use an inhaler? If so, always replace its cap after use. The importance of replacing caps on inhalers was recently illustrated when a woman accidentally inhaled a small earring while using her asthma medicine. She got her uncapped inhaler from her purse. As she inhaled the medicine, she felt a painful scratch in her throat and started coughing blood. She was taken to the emergency department, where the earring was removed from her lung. If the inhaler's cap had been in place, the loose earring in her purse would not have gotten into the inhaler.

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Become More Familiar with the Medicine You Take... Learn the Generic Name

Medicines all have one generic name and perhaps one or more brand names. The brand name is chosen by the drug company. The generic name is assigned by an official body, the United States Adopted Names (USAN) Council. You probably know, for example, that Advil and Motrin are brand names for the generic medicine ibuprofen. Knowing that Advil, Motrin, and ibuprofen are all the same medicine alerts you to an important risk—that taking these medicines together could add up to an overdose.

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Warning! Dilute Sertraline Oral Concentrate

A medicine commonly used to treat depression, sertraline (Zoloft), is available as a tablet or a concentrated oral liquid. The oral liquid form is very potent and must first be diluted in a specific beverage to make it easier to swallow. However, many healthcare providers and consumers are unfamiliar with the need to dilute this medicine before use.

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