Thank you for your willingness to report an error or hazard to the ISMP National Vaccine Errors Reporting Program (VERS), a national vaccine safety surveillance program developed in cooperation with the California Department of Public Health Immunization Branch and operated by ISMP. When reporting an error or hazard:

  • Tell us the story of what went wrong or could go wrong, the causes or contributing factors, how the event or condition was discovered or intercepted, and the actual or potential outcome of the involved patient(s). 
  • Answer the specific questions as best you can.
  • Be sure to include the names, dosage forms, and dose/strength of all involved products. For product-specific concerns (e.g., labeling and packaging risks), please include the manufacturer.
  • Share your recommendations for error prevention.
  • If possible, submit associated materials (e.g., photographs of products, containers, labels, de-identified prescription orders) that help support the report being submitted.

Please complete the form below and click on the “Submit Report” button to report an error or hazard to the ISMP National Vaccine Errors Reporting Program.

If you want to report a non-preventable adverse reaction to a vaccine product, please visit the US Department of Health and Human Services Vaccine Adverse Event Reporting System (VAERS) (http://vaers.hhs.gov).

Event Detail Questions

* indicates a required field

1. Report submission type (select one): * 



2. Event date:
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Open the calendar popup.
 (MM/DD/YYYY) *   

3. Vaccine(s) involved in the event: *  
Complete this form and then click the button below to include vaccine product information.

STEP 1 -Search by:

STEP 2 - Specify vaccine information

Brand name: *
select

Generic name: *
select

Manufacturer: *
select

Dosage (optional):
Lot# (optional):
Expiration date (optional):
NDC (optional):


STEP 3 - Click button to include vaccine with report

Vaccines included with this report
Brand nameGeneric nameManufacturer 
No Vaccines have been added


4. Age of patient at the time of the event: *      
 years and/or    months  and/or   days.
5. Type of event (select one): *       














6. Describe the event. Please do NOT submit any provider or patient identifiable information when submitting reports to ISMP.  *     

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7. Contributing factors (select all that apply): *    
*** Select the type of event above first ***

 
     

8. Type of facility where the event occurred (select one): *  










If "Other" then please specify:   

 

9. Type of practice (select one) *  







If "Other" then please specify:    
10. Type of practitioner(s) involved in the event (select all that apply): *










If "Other" then please specify:    

Reporter Information

Name (optional):
Email:   *     
Confirm Email:   *  
State:
select
 *  
Phone (optional):
Is reporter same as person involved in the event? *  



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