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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

Before Leaving the Doctor’s Office, Expect Medication Information

It was double trouble for a patient when she and her doctor both made errors and it led to a 4-fold overdose of an antidepressant medication, CELEXA (citalopram Hydrobromide). The patient was starting this medication for the first time and after three days she began to experience severe anxiety, agitation, nausea, and severe fatigue. She called her doctor about her symptoms. The error was identified when they reviewed the medication together and realized what was causing the problem – a medication error.

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Mom Hopes Son’s Overdose Spurs Prevention Efforts

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Don't Confuse Depakote with Depakote ER

Depakote (divalproex sodium) ER is a medicine used to treat seizure disorders, migraine headaches, and certain mental illnesses such as bipolar disorder. The "ER" part of the name stands for "extended release," meaning the contents of the medicine are released slowly, not all at once, after you take the medicine. So, Depakote ER should be taken just once a day.

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Over-The-Counter Eye Drop and Nasal Spray Danger

Here’s advice about seemingly harmless over-the-counter eye drops, such as Visine and similar products containing the active ingredients tetrahydrozoline, oxymetazoline, or naphazoline. These drugs are quite dangerous if ingested. Severe side effects have been documented after swallowing as little as a half of teaspoonful.

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