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...

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...

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...

Joint Hazard Alert! Action Needed to Address Incorrect Information on the Broselow Rainbow Tape

revised January 22, 2026 Institute for Safe Medication Practices (ISMP)American Society of Health-System Pharmacists (ASHP)Pediatric Pharmacy Association (PPA) The Broselow Rainbow Tape is a height...