ISMP Consumer Error Reporting


Welcome to the Consumer's Medication Error Reporting Form!

Use the form below to report a medication error to the Institute for Safe Medication Practices


Please answer the questions as completely and accurately as possible. Your answers will help us to better understand the type of errors that are happening, where and why they are happening, and how to help those people being affected.
 

1. Please describe what you would like to report to us.

Other (please specify)

2. Are you submitting this report on behalf of yourself or someone else?


If answered "someone else" please indicate the relationship to you.
   

3. Please indicate the approximate date of the error or event or discovery of the medication safety concern:

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4. If an error or event happened, what was the age of the person affected at the time of the error/event?

Patient's age:

5. Is the affected person male or female?


6. Please describe the error or potential error.  Please include the medications involved and if known, the manufacturer of the product/s. Please include as much information as possible such as: the dosage form (capsule, tablet, injection, etc), concentration or strength, etc. 

ERROR DESCRIPTION  
Be sure to include the names of all drugs involved.




7. How was the error/concern discovered?
 


8. If reporting an actual medication error, please indicate where this error took place.










If "other" then please specify:    

9. Please include any product photographs, scans of doctor's prescriptions, images of associated records, etc. that might help us understand your report. Be sure not to include any personally identifiable information such as your name, social security number, etc. (only image files are accepted)


10. If this report is related to a pharmacy dispensing error, please indicate how the prescription was filled.






If other then please specify:


11. If this report is related to a pharmacy dispensing error, please indicate the type of pharmacy the prescription was filled in.



Comment:
 

 

 12. What was the final outcome to the person/patient involved in the error?




Comments:


13. What do you think should have been done to avoid this type of mistake or your safety concern?

 


14. Did any of the following happen to the person because of the error (check all that apply):













15. Were you or the person involved in the error provided with specific instructions regarding how to take the medicine?


16. Do you have any additional information you would like to share in this report? If so, please describe in the space provided.


Optional Personal Information

All communications are strictly confidential. ISMP will not disclose your identity to any individuals or outside organizations.  Although your contact information is optional please keep in mind that we may need to be able to contact you if we should have a question.

17. Please provide the following informatin:

Company:
Address2:
Country:


18. Our organization shares information with the FDA, in confidence, when we receive a report. Both organizations (ISMP, FDA) utilize these reports to identify and address drug-related problems by working with drug manufacturers, scientists and others. Please indicate which of the following organizations we may share your report with (your information will be handled 100% securely and confidentially):

Share with FDA:



Share with Manufacturer: