Insulin Mistaken for Influenza Vaccine in School Clinic

As organizations prepare for influenza season, it is important to recognize how changes in vaccine presentation can introduce new medication safety risks. ISMP was informed of an event in which a s...

Addressing Discrepancies in Prescription Billing Units and Dispensing

Problem: Determining the correct medication billing units can be a challenging process for outpatient, specialty, and ambulatory care pharmacies. Billing units and the appropriate billing quantity ...

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...

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...

Patient Access to Appropriately Sized Oral/Enteral Medication Syringes Is Needed

Problem: Errors with enteral medication administration can lead to complications and patient harm. The most vulnerable patients include those with feeding tubes who receive enteral liquid medicatio...

Implement High-Leverage and Layered Risk-Reduction Strategies Using ISMP’s Hierarchy of Effectiveness

Healthcare is a complex and multifaceted field where some level of risk is ever-present. The groundbreaking 1999 Institute of Medicine report, "To Err is Human," rocked the world by estimating that...

Safeguard Pediatric Patients—Act Upon the 2025 KIDs List

PROBLEM: Pediatric patients are vulnerable to higher rates of adverse drug events for a variety of reasons, including frequent off-label drug usage, individualized dose calculations, and age-relate...

Warning! Overwrap Labeled Potassium Chloride 10 mEq/ 100 mL May Contain Potassium Chloride 20 mEq/ 50 mL Premixed IV Bag

A prescriber ordered a potassium chloride 10 mEq/100 mL infusion for a patient with a peripheral intravenous (IV) line. The nurse removed a bag from the automated dispensing cabinet (ADC) labeled p...

Take Action on the Top Five Themes Identified During ISMP Consultations

Seeking expertise from external sources and learning about errors that have occurred in other hospitals prompts the evaluation of similar risks within your own organization that may otherwise be hi...

Is Your Organization Still Punishing Human Error?

Discover the Truth. Reimagine Shared Accountability. Build a More Just Culture.  Despite decades of progress, many healthcare professionals still fear blame when mistakes happen. The data tells a s...

Call to Action: Practitioners Need to Warn Patients About Purchasing Counterfeit Drugs Online

Problem: Practitioners should be on guard for patients who may present to different healthcare settings with adverse reactions after knowingly or unknowingly taking substandard and falsified (SF) d...

Do You Know What Is Going on in Your OR? The Anesthesiology Residents' Perspective

PROBLEM: If you interviewed members of your perioperative team to ask what keeps them up at night, you might be surprised by what you uncover. The operating room (OR) represents an area with high p...

What’s in a Name?

The “-grastim” drug stem name Medications that end with the suffix “-grastim” belong to a class of medications known as granulocyte colony-stimulating factors (G-CSF). This class of medications bel...

Implement Strategies to Prevent Persistent Medication Errors and Hazards: 2025

Reflecting on events that occurred in 2024, we have identified four concerns related to medication safety, which were included in ECRI’s Top 10 Patient Safety Concerns for 2025 or ECRI’s Top 10 Hea...

Action Needed to Address Risk With Custom and Multi-Chamber Bag Parenteral Nutrition—Part II

PROBLEM: The complexity of parenteral nutrition (PN) coupled with the heightened risk of causing significant patient harm when used in error, calls for targeted safeguards throughout the medication...

Survey Exposes Risks with Custom and Multi-Chamber Bag Parenteral Nutrition—Part I

PROBLEM: Parenteral nutrition (PN) is a complex life-sustaining therapy for patients who cannot intake adequate oral or enteral nutrition. It can contain more than 40 ingredients and is considered ...

A Deeper Dive into Active Failures and Accountability Using Just Culture Principles—Part II

PROBLEM: In our last newsletter, in the main article, Another case of nursing criminalization – Long-term care facilities must improve systems, not blame nurses - Part I, we discussed how a series ...