Your Reports at Work: Fresenius Kabi Morphine Recall

Our July 30, 2026 article, Morphine 2 mg/mL Prefilled Syringes Contain HYDROmorphone 0.5 mg/0.5 mL, discussed how a nurse removed a prefilled syringe of what they thought was morphine 2 mg/mL from ...

Survey Shows Room for Improvement with Three New Best Practices for Hospitals

In our March 12, 2026 newsletter, we invited hospitals to participate in a short survey to establish a baseline of implementation for the three new Best Practices released in the 2026-2027 ISMP Tar...

Morphine 2 mg/mL Prefilled Syringes Contain HYDROmorphone 0.5 mg/0.5 mL!

A nurse removed a prefilled syringe of what they thought was morphine 2 mg/mL from an automated dispensing cabinet (ADC). The nurse identified that while the syringe packaging contained a tamper-ev...

Preventing the Preventable: How System Design and Safety Culture Transform Healthcare

Preventable harm remains one of the most persistent challenges facing healthcare organizations today. While many safety initiatives focus on individual performance, lasting improvement requires som...

Compounded Peptide Products Marketed as Wellness Therapies

The growing popularity of “wellness peptides” has outpaced the clinical evidence needed to support their safety and effectiveness. Marketed for benefits such as muscle growth, anti-aging, and recov...

Falling Short of Safety: Partnering with Families to Prevent Healthcare-Related Falls

Preventing falls in a healthcare facility isn’t just a clinical metric, it’s a team sport. While we have high-tech beds and sophisticated risk assessment tools, a truly resilient systems-based appr...

Have a Game Plan—Setting a Goal for Medication Safety During the World Cup

Problem With the United States, Canada, and Mexico hosting the FIFA (Fédération Internationale de Football Association [French] or International Federation of Association Football [English]) World ...

Warning! Enteral Feeding Tube Declogging System Uses a Luer Lock Syringe

A nurse reported concerns with CLOG ZAPPER, an enteral feeding tube declogging system (made by Avanos) used to clear blockages from enteral feeding formulations. According to the instructions for u...

Striking the Right Balance: Navigating the Promises and Pitfalls of Fall Prevention Technology

Patient falls are a significant and costly problem in healthcare. In the United States alone, between 700,000 and 1 million patients fall in hospitals each year. These falls can lead to serious inj...