We thank you for your willingness to report an error to the ISMP National Vaccine Errors Reporting Program. The report 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 US Food and Drug Administration (FDA). When applicable, the report will also be shared with product vendors to inform them about pharmaceutical labeling, packaging, and nomenclature issues that may foster errors by their design. Your name, contact information, and location will NOT be included without your permission.

When reporting an error or hazardous condition:

  • 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 do NOT submit any provider- or patient-identifiable information.

You may prefer to report an adverse vaccine event to ISMP as a federally certified Patient Safety Organization (PSO). As a PSO, ISMP can provide legal protection of patient safety information (e.g., error reports, root cause analysis) prepared within your patient safety evaluation system for the purpose of reporting to a PSO. There is no cost associated with reporting an event to ISMP as a PSO. Click here  to learn more and to report an event to ISMP as a PSO.

Otherwise, please complete the form below and click on the “Submit Report” button to report the event to the ISMP National Vaccine Errors Reporting Program.

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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