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 an automated dispensing cabinet (ADC) and identified that while the syringe packaging contained a tamper-evident seal labeled “Morphine 2 mg/mL,” the syringe was labeled DILAUDID (HYDROmorphone) 0.5 mg/0.5 mL. The hospital found 6 impacted syringes, made by Fresenius Kabi. The HYDROmorphone prefilled syringe had an NDC of 76045-009-96, lot number 6402813, and expiration date 12/31/28. The syringe was removed from a carton labeled morphine 2 mg/mL, with an NDC of 76045-004-11, lot number 6402820, and expiration date 12/31/28.
Based on this report, Fresenius Kabi recalled this lot number (6402820) of morphine, as it may contain a prefilled syringe of HYDROmorphone. Fresenius Kabi is notifying its distributors and customers and is arranging for return of the recalled product. If your organization purchases this product, review all inventory to ensure you do not have impacted syringes, or if found, contact Fresenius Kabi to arrange for return. Notify staff to be vigilant when checking the prefilled syringe labels for Fresenius Kabi’s HYDROmorphone and morphine injection, regardless of the lot.
We want to thank you for reporting this to us. We cannot emphasize enough how important it is to report errors to ISMP. Please keep the reports coming!
