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...

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...

Worksheet for the ISMP Targeted Medication Safety Best Practices for Hospitals

Analyze your current status with implementation.

Targeted Medication Safety Best Practices for Hospitals

Consensus-based best practices for issues that continue to cause fatal and harmful errors.

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...

Multi-Chamber Bag Parenteral Nutrition Consensus Statements

This document presents consensus statements developed by the Institute for Safe Medication Practices (ISMP) and the American Society for Parenteral and Enteral Nutrition (ASPEN) regarding the use o...

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...

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...

Guidelines for Safe Electronic Communication of Medication Information

Strategies to safely present drug information in various electronic formats.

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...