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.

📊 How is your hospital doing with implementing the newest ISMP Best Practices? Our survey results suggest there is room ...
08/21/2026

📊 How is your hospital doing with implementing the newest ISMP Best Practices? Our survey results suggest there is room for improvement. Resource constraints, workflow drift, and technology limitations emerged as the most common barriers, and ongoing monitoring as the most frequently reported enabler.

Earlier this year, we invited hospitals to complete a survey establishing a baseline for the three new items in the 2026-2027 Targeted Medication Safety Best Practices for Hospitals, which focus on:
💉 Use of IV push medications 🏷️ Barcode scanning of patient ID bands and products 🛡️ Culture of safety

📖 Read our free article for survey respondents' lessons learned on what is working and what is getting in the way for each individual practice: https://hubs.la/Q04tCSRT0

⛈️ Weather presented a few challenges, but it didn't stop an ISMP-led discussion on parenteral nutrition safety (PN) at ...
08/18/2026

⛈️ Weather presented a few challenges, but it didn't stop an ISMP-led discussion on parenteral nutrition safety (PN) at the Society of Health-System Pharmacists Annual Meeting.

Using an interactive patient case study, Dr. Michael Michaane from Columbia University (joining virtually due to travel delays), Angela Bingham from the Philadelphia College of Pharmacy, and ISMP's Christina Michalek examined how clinicians can navigate complex nutrition support decisions while reducing medication-related risks.

Key takeaways included:
✅ When PN and supplemental PN are most appropriate
✅ Strategies for managing lipid shortages and selecting alternative lipid emulsions
✅ Safety considerations for multi-chamber bag PN products
✅ Why PN should be treated as a high-alert medication requiring careful prescribing, monitoring, and collaboration across the care team

Missed the session? Learn more through ISMP's on-demand educational program: https://hubs.la/Q04tbFcd0

⚠️ Your error reports at work: morphine recall.A nurse recently pulled what should have been morphine 2 mg/mL from an au...
08/13/2026

⚠️ Your error reports at work: morphine recall.

A nurse recently pulled what should have been morphine 2 mg/mL from an automated dispensing cabinet (ADC). The carton and tamper-evident seal said "Morphine 2 mg/mL," but the syringe inside was labeled DILAUDID (HYDROmorphone) 0.5 mg/0.5 mL. The hospital found 6 mislabeled syringes and reported it to ISMP.

That report mattered. Fresenius Kabi has now issued a voluntary nationwide recall of morphine with lot 6402820, which may contain HYDROmorphone syringes mislabeled as morphine.

What you can do:
🔹 Check inventory for lot 6402820 (morphine) and 6402813 (HYDROmorphone)
🔹 If found, contact Fresenius Kabi for return
🔹 Remind staff to check the syringe label itself, not just the carton, regardless of lot

📣 What you share with us can drive nationwide safety action — please keep the reports coming.

➡️ Report an error to ISMP: https://hubs.la/Q04sWGq40

🔗 More on recall: https://hubs.la/Q04sWyY90

The White House signed an executive order that reduces the vaccines recommended for all U.S. children from 18 immunizati...
08/13/2026

The White House signed an executive order that reduces the vaccines recommended for all U.S. children from 18 immunizations against vaccine-preventable diseases to 11, reclassifies several vaccines for use in "high-risk groups" and others in "shared clinical decision-making" categories, and directs that combination vaccines such as MMR be administered as separate individual vaccinations given at separate visits. ECRI and ISMP are concerned that this latest directive was issued without a transparent, evidence-based review process and is not supported by new scientific evidence.

The current scientific consensus, backed by decades of epidemiologic research, continues to affirm that the existing pediatric immunization schedule is safe and effective, and that vaccination is not associated with autism. Altering a proven schedule without credible new evidence fuels confusion that could threaten patient safety and undermine public health.

Read our full position statement: https://hubs.la/Q04sX8Zf0

🚨 Reminder: Nominate a Medication Safety Champion! 🏆The ISMP Cheers Awards nomination deadline is August 15, 2026!Do you...
08/05/2026

🚨 Reminder: Nominate a Medication Safety Champion! 🏆
The ISMP Cheers Awards nomination deadline is August 15, 2026!

Do you know an individual, team, or organization that has gone above and beyond to improve medication safety?

Whether they’ve launched a groundbreaking safety initiative, improved processes, or led change across their organization—now’s the time to recognize their work.

✨ Nominate them for an ISMP Cheers Award—self-nominations are welcome!
Honorees represent all healthcare disciplines and practice settings.

👉 Learn more and submit your nomination: https://hubs.la/Q04p566S0

Thank You, Ann Shastay 💙 After 18 years of dedicated service to ISMP, Ann Shastay, MSN, RN, AOCN, Senior Manager of Publ...
07/31/2026

Thank You, Ann Shastay 💙 After 18 years of dedicated service to ISMP, Ann Shastay, MSN, RN, AOCN, Senior Manager of Publications, has retired.

An Advanced Oncology Certified Nurse, Ann brought her clinical expertise, editorial leadership, and passion for medication safety to ISMP publications, website for consumers, self-assessment tools, and professional collaborations. She also served as adjunct faculty at Temple University School of Pharmacy and contributed to leading nursing publications and editorial boards.

We are grateful for Ann's lasting impact on healthcare professionals, patients, and families, and we wish her all the best in retirement.

As Ann begins this new chapter, Shannon Bertagnoli, PharmD, Principal Consultant, Membership, will serve as the lead contact for ISMP publications moving forward.

Please join us in celebrating Ann’s many contributions to ISMP and the healthcare community and wishing her a wonderful retirement.

The FDA Pharmacy Compounding Advisory Committee (PCAC) decided to recommend adding most of the peptides under considerat...
07/27/2026

The FDA Pharmacy Compounding Advisory Committee (PCAC) decided to recommend adding most of the peptides under consideration during its July 23-24, 2026, meeting to the 503A Bulks List, despite substantial gaps in evidence for the peptides’ safety or efficacy. Demand for these peptide products has grown rapidly, but the science has not kept pace and data on their safety and efficacy remains limited or absent. ECRI and ISMP continue to believe that compounding access should only be granted when there is clear evidence of safety and efficacy, proof of robust quality controls, and appropriate pharmacovigilance requirements.

Read the full statement from ECRI and ISMP: https://hubs.la/Q04qW94Z0

Parenteral nutrition therapy continues to evolve—and healthcare teams need practical strategies to optimize safety and p...
07/21/2026

Parenteral nutrition therapy continues to evolve—and healthcare teams need practical strategies to optimize safety and patient outcomes.

Join ISMP experts and clinical leaders for “Innovations and Safety in Parenteral Nutrition – Insights from ISMP” to explore emerging practices, alternative lipid sources, and implementation considerations for safe PN delivery.

📅 Friday, August 7, 2026
📍 FSHP Annual Meeting | Renaissance Orlando at SeaWorld
🎓 CE credit available

Reserve your spot: https://hubs.la/Q04jYCLF0

🏆 Nominate safety leaders for ISMP Cheers Awards!Do you know an individual, organization, or group that has shown extrao...
07/14/2026

🏆 Nominate safety leaders for ISMP Cheers Awards!

Do you know an individual, organization, or group that has shown extraordinary medication safety leadership and innovation?

⭐ Nominate them for an ISMP Cheers Award—the deadline is August 15, 2026.

Each year, ISMP celebrates individuals, healthcare organizations, and group collaboratives that have completed outstanding projects or programs, developed and implemented standards around medication safety, or undertaken other unique medication safety initiatives.

⚕️ Safety leaders from all healthcare disciplines and practice areas are encouraged to submit. Self-nominations are accepted.

For awards criteria and to submit a nomination: https://hubs.la/Q04p5gsG0

🌏 A Global Classroom in ActionTwenty-four healthcare professionals. Three countries. Three days. One shared goal: safer ...
07/13/2026

🌏 A Global Classroom in Action

Twenty-four healthcare professionals. Three countries. Three days. One shared goal: safer medication-use systems.

ISMP just delivered its first-ever live virtual Medication Safety Intensive (MSI) Workshop in the Asia Pacific time zone, bringing together medication safety officers, pharmacists, nurses, and quality leaders from Australia and Singapore.

Together, participants tackled systems-based error analysis, high-leverage risk reduction strategies, and practical tools ready to apply in their own organizations — proving that world-class medication safety education knows no borders.

Thank you to everyone who joined us. Your dedication made this workshop a success. 👏

👉 Wherever you practice, ISMP can bring expert training directly to you. Learn more about upcoming workshops: https://hubs.la/Q04p59Pf0

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