Please consider the following items when completing this online reporting form:

  • Answer the questions as best you can.
  • Tell us the story of what went wrong, any causes or contributing factors, how the event was discovered or intercepted, and the outcome of the patient(s) involved. 
  • Share your recommendations for error prevention.
  • Provide any associated materials (e.g., product photographs, containers, labels, de-identified prescription order scans) that help support the information being submitted.

ISMP guarantees confidentiality of information received. ISMP is a federally certified patient safety organization (PSO), providing legal protection and confidentiality for submitted patient safety data and error reports. Click here  to learn more about legal protection of patient safety information submitted to ISMP.

The report information will be forwarded, in confidence, to the Vaccine Adverse Event Reporting System (VAERS), a national vaccine safety surveillance program co-sponsored by the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA). When applicable, the report information will be forwarded to product vendors to inform them about vaccine labeling, packaging, and nomenclature issues that may foster errors by their design. Your name and contact information will not be shared unless you grant permission.

If you are reporting an unpreventable adverse reaction to a vaccine product, please visit VAERS (http://vaers.hhs.gov).

Please do NOT submit any provider or patient identifiable information when submitting reports to ISMP.

Event Detail Questions

* indicates a required field

1. Report submission type (select one): * 



2. Event date:
RadDatePicker
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. Describe the event. Please do NOT submit any provider or patient identifiable information when submitting reports to ISMP.  *     

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














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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