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...