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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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Doggy Drops in Your Child's Ear?

Who would ever make that mistake? Well, people do. A father told the babysitter to put his son's ear drops in his right ear before bed, and the careful babysitter did just that. She found ear drops labeled "put two drops in right ear" in the medicine cabinet, and instilled the ear drops into the child's right ear. But the family's dog also had a bottle of ear drops, which were the drops the babysitter used. The son's ear drops were in the refrigerator. Luckily, the child was not harmed by the dog's ear drops.

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Top 10 Tips to Keep Pets Safe Around Medicines

Most people are aware of the need to keep medications out of children’s reach, but they don’t necessarily realize that similar rules apply when it comes to keeping pets safe. Pets can also get into medications that are not intended for them, which could cause harm. One case in point was recently reported.

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Fleet Enema Label Is Misleading–It’s Not Just “Saline”

Fleet enemas are commonly used in both healthcare facilities and in the home to relieve constipation. These seemingly safe treatments are available over-the-counter (OTC). As shown in Figure 1, the product label says, “Fleet Enema Saline.” This would lead you to believe that the enema was basically made of saline (salt or sodium chloride and water). However, this product actually contains phosphate which can cause bad side effects, especially in elderly people or those with kidney disease.

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