Institute for Safe Medication Practices

Institute for Safe Medication Practices ISMP is the nation’s only 501c (3) nonprofit organization devoted entirely to medication error prevention and safe medication use.

Staying current with USP requirements is essential for ensuring compliance and advancing patient safety in sterile compo...
06/18/2026

Staying current with USP requirements is essential for ensuring compliance and advancing patient safety in sterile compounding.

Join ASHP for free educational opportunities that provide practical guidance and real-world insights to help pharmacy professionals strengthen their sterile compounding practices:

✔ Making USP as Easy as 123: Overcoming Sterile Compounding Insourcing Challenges and Adult Versus Pediatric Considerations: https://hubs.la/Q04khZl00

✔ Level Up Your BUD Game: An Interactive, Choose Your Own Adventure Activity on Beyond Use Dates in Sterile Compounding: https://hubs.la/Q04khWfy0

✔ Frontline Conversations: USP 797 in Practice—Resources, Risk, and Readiness: https://hubs.la/Q04kj2p20

Plus, stay tuned for the next installment of the Frontline Conversations series, coming soon.

Explore the activities, earn CE credit, and gain actionable strategies you can apply in your practice.

⚠️Warning: ISMP recently highlighted a safety concern involving CLOG ZAPPER, an enteral feeding tube declogging system.A...
06/16/2026

⚠️Warning: ISMP recently highlighted a safety concern involving CLOG ZAPPER, an enteral feeding tube declogging system.

A change from an oral slip-tip syringe to a luer lock syringe could lead to tubing misconnections--practitioners could inadvertently connect the syringe directly to a patient's IV tubing, leading to wrong-route administration.

If your organization uses this product, immediately inform staff of this risk. Educate practitioners about the need to remove the clear connector from the blue applicator before use to prevent leakage and emphasize why the syringe should never be stored at the bedside.

🔎 Read ISMP's newsletter article for more recommendations: https://hubs.la/Q04lyY6F0

06/15/2026

A patient self-injected a counterfeit GLP-1 medication. They ended up in the emergency department.

The ER notified ISMP — and it's a warning the entire care community needs to hear.

As demand for GLP-1 therapies surges, so does the counterfeit market. These products can look legitimate. But the signs are there if you know what to look for:
- Misspellings on the packaging
- Missing or unclear instructions
- Incomplete or absent labeling

Patients sourcing medications outside of traditional pharmacy channels — whether due to cost, shortages, or availability — are especially vulnerable.

This isn't a hypothetical risk. It has already happened.

▶️ Watch the full video to hear directly from a nurse and pharmacist on what's at stake with GLP-1 safety: https://hubs.la/Q04jrslC0

Registration is open for ISMP's August 13–14 Acute Care Medication Safety Intensive Workshop.This two-day virtual worksh...
06/12/2026

Registration is open for ISMP's August 13–14 Acute Care Medication Safety Intensive Workshop.

This two-day virtual workshop provides practical guidance to help you reduce risk, improve processes, and advance medication safety in your organization.

👉 Save your seat: https://hubs.la/Q03_0lfs0

06/08/2026

Reusing a single-dose vial to save money could land a patient in the hospital.

It's an understandable impulse — GLP-1 medications are expensive, and that vial looks like it has more in it. But if it's labeled single-use, there's a critical reason to stop there.

Single-dose vials contain no preservatives. No antimicrobial protection of any kind. Once opened, bacteria can begin to grow in as little as one hour.

Reusing that vial isn't stretching a medication — it's introducing a contamination risk directly into the injection.

One dose. One time. That's not a guideline. It's a patient safety line.

▶️ Watch the full video to hear a nurse and pharmacist break down this and other critical GLP-1 safety gaps: https://hubs.la/Q04jppPv0

💉 Free CE credit. Real impact. Every drug drawn up in the OR is a chance for error — and medication preparation is one o...
06/05/2026

💉 Free CE credit. Real impact.

Every drug drawn up in the OR is a chance for error — and medication preparation is one of the most overlooked risks in perioperative care.

ISMP's new on-demand webinar breaks down how ready-to-administer (RTA) injectables can reduce error risk, improve efficiency, and support safer anesthesia workflows.

▶️ Watch now and earn up to 1 hour of free CE: https://hubs.la/Q04k9yn10

06/01/2026

GLP-1 medications are changing lives — but a dangerous dosing gap is sending patients to the hospital.

When a patient is prescribed a GLP-1 therapy, their dose is written in milligrams. But the syringe they use at home is labeled in units — a disconnect that's causing real harm.

Confused by the difference, some patients underdose and lose the benefit of their medication. Others overdose, landing in the emergency department.

This isn't a patient education failure. It's a system safety gap.

In this clip, a nurse and pharmacist break down exactly how this confusion happens — and why it matters for every care team involved in GLP-1 prescribing.

▶️ Watch the full video: https://hubs.la/Q04jy8qz0

🏡💊 Senior care organizations face unique medication safety challenges—from complex medication regimens and staffing pres...
05/29/2026

🏡💊 Senior care organizations face unique medication safety challenges—from complex medication regimens and staffing pressures to transitions of care and age-related vulnerabilities that can increase the risk of harm. At the 2026 LeadingAge PA Annual Conference, ISMP’s Christina Michalek joined ECRI’s Georgia Reiner to present on how organizations can strengthen medication safety through systems thinking, Just Culture principles, and proactive event reporting.

Key themes from the session included:
🔍 Looking beyond frontline mistakes to identify latent system failures
🗣️ Creating environments where near misses and safety concerns are openly reported and analyzed
🛡️ Using high-leverage risk-reduction strategies instead of relying only on education or reminders
📈 Applying structured event investigation processes to drive learning and improvement
👵Supporting safer medication use for older adults through the Age-Friendly Health Systems 4Ms framework

One important reminder from the discussion: organizations that report more medication safety events and near misses have stronger safety cultures—not less safe care.

🏥 ISMP Consulting Services can help senior and long-term care facilities identify medication-use system vulnerabilities and implement practical, evidence-based safety improvements. Learn more: https://hubs.la/Q04hSWbZ0

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