California’s New Patient Safety Law Elevates Pharmacists’ Role in Discharge Medication Safety

Pharmacy Times interviewed Rita Shane, PharmD, FASHP, FCSHP, vice president, chief pharmacy officer, and professor of medicine at Cedars-Sinai Medical Center, and associate dean of clinical pharmacy services at UCSF School of Pharmacy, who explained that California’s new patient safety law—effective January 1—requires pharmacists to review discharge medication lists for high-risk patients to prevent harmful and often overlooked medication errors during care transitions. She highlights that complex patients frequently see multiple prescribers, making pharmacist-led medication review essential for ensuring accuracy and preventing readmissions. This amendment expands pharmacists’ responsibilities beyond inpatient safety by mandating accurate medication profiles at both admission and discharge for hospitals over 100 beds.

Shane notes that hospital leaders will now collaborate with medical staff to define high-risk populations and allocate resources for compliance, emphasizing that California is uniquely positioned with two laws leveraging pharmacists’ expertise to reduce medication errors, serving as a national model for improving patient outcomes.

Shane’s passion for the profession has been recognized by ASHP, ISMP, and CSHP. Her advocacy journey has led to new laws advancing pharmacy practice. She has published over 100 papers and has given over 250 presentations at the state, national, and international levels.

Pharmacy Times: Can you describe the new California patient safety law taking effect on January 1 and explain why this amendment is so significant?

Rita Shane, PharmD, FASHP, FCSHP: The new law ensures that discharge medication lists for high-risk patients are reviewed by pharmacists to prevent harmful medication errors when patients leave the hospital. Evidence demonstrates that hospital pharmacists performing discharge medication reviews prevented at least 1 error in up to 60% of patients.

Pharmacy Times: What gap in patient safety does this legislation aim to close, particularly regarding medication reviews at hospital discharge? Why are pharmacist-led medication reviews so critical during care transitions, especially at discharge for high-risk patients?

Shane: The current process is challenging since complex patients on multiple medications may have multiple physicians responsible for their care. By having the pharmacists, who have the training and expertise in medication management, conduct discharge medication reviews, they can collaborate with physicians and advanced practice providers to ensure the lists are accurate.

Pharmacy Times: What specific responsibilities do pharmacists have in preventing medication errors during admission and discharge?

Shane: California law requires pharmacy staff to ensure the accuracy of medication profiles (lists) for high-risk patients at both admission and discharge for hospitals greater than 100 beds. 

Pharmacy Times: How does this law reinforce or expand the role of pharmacists in safeguarding patient outcomes?

Shane: Traditionally, pharmacists in hospital settings have focused on medication safety during the hospital episode. This law extends the safety role of the pharmacist to discharge, which is a critical transition for high-risk patients who may have multiple chronic diseases and therefore are on multiple medications.

Pharmacy Times: How do you anticipate hospitals will prepare to comply with the new law beginning January 1? 

Shane: Hospital pharmacy leaders will work with their medical staff and administration to define high-risk patients and determine how to allocate resources to support this new law.

Pharmacy Times: Any final or closing thoughts?

Shane: California is the only state to have 2 laws that leverage the expertise of pharmacists to protect high-risk patients from admission and discharge medication errors. When these medication lists are inaccurate, they result in medication errors that can lead to harm during hospitalization, and medication errors at discharge can result in harm necessitating readmissions, respectively. Given the evidence demonstrating 8 errors per high-risk patient on admission and 2 errors per high-risk patient at discharge, this important patient safety legislation serves as a model for the nation.