About the ISMP Summit
The ISMP Medication Safety Summit ↗ is the flagship conference of the Institute for Safe Medication Practices ↗ — the independent US non-profit that analyses medication error reports, issues safety alerts, and develops evidence-based prevention guidelines used by hospitals, pharmacies, and regulators nationwide.
The 2026 Summit in Philadelphia addresses the most pressing patient safety challenges facing health systems today: smart infusion pump programming errors, high-alert medication failures, look-alike/sound-alike (LASA) name confusion, and the transition to electronic prescribing systems with inadequate safety checks. See the medication errors guide for the NCC MERP error taxonomy used throughout ISMP's work.
ISMP high-alert medications — selected examples
| Drug / class | Error type | Key safeguard |
|---|---|---|
| Concentrated KCl (≥2 mEq/mL) | IV bolus instead of diluted infusion → cardiac arrest | Remove from floor stock; pharmacy-only dispensing |
| Insulin (all formulations) | Unit/mL confusion; U-500 for U-100; wrong pen | Standard concentrations; insulin-only syringes; double-check |
| Unfractionated heparin (IV) | 10-fold overdose; wrong weight-based protocol | Pre-printed weight-based protocols; independent check |
| Warfarin | Missed INR; drug interactions not acted on | INR monitoring alerts; DDI screening at dispensing |
| Neuromuscular blocking agents | Given instead of sedative; patient not ventilated | Separate storage; warning label "causes respiratory arrest" |
| IV opioids (morphine, hydromorphone) | 10× overdose; hydromorphone confused with morphine | Smart pump drug libraries; tall-man lettering; PCA limits |
| Methotrexate (oral low-dose) | Daily instead of weekly → fatal | "Weekly dose only" labelling; dispensing alerts; patient education |
Summit session tracks
LASA & Naming Safeguards
Tall-man lettering implementation, ISMP confused drug names list updates, IT alert fatigue reduction, storage segregation strategies.
Smart Infusion Pump Safety
Drug library design, dose error reduction software (DERS) compliance rates, pump programming workflow, interoperability with CPOE systems.
High-Alert Drug Protocols
Independent double-check policies, anticoagulant stewardship, insulin safety protocols, concentrated electrolyte removal programmes.
Error Reporting & Culture
Just culture frameworks, near-miss reporting, MERP submission guidance, root cause analysis (RCA) methodology, safety culture measurement.
Transitions of Care Safety
Medication reconciliation failures, discharge counselling gaps, community pharmacy handoff, electronic prescribing error patterns.
Technology & Automation
Automated dispensing cabinet (ADC) safety, barcode medication administration (BCMA), AI-assisted prescribing error detection, EHR alert optimisation.