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...

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...

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...