Pharmacists: Pioneers of Inpatient Medication Safety


Improving patient safety and reducing harmful events is a team effort that includes both executive leadership and management as well as front line care teams.

As the health care industry works towards an equitable and universal standard of care, patient safety remains amongst the top priorities for health systems in 2023. However, amid COVID-19 challenges, rising costs, labor shortages, and supply chain bottlenecks, recent data show that 1 in 4 patients admitted to hospitals in the United States will experience harm during their stay.1 Of these events, medication-related errors were responsible for the majority of patient harm. Hospital harm events are associated with higher mortality rates, longer hospital stays, and increased provider and patient costs.2

Improving patient safety and reducing harmful events is a team effort that includes both executive leadership and management as well as front line care teams. When it comes to medication safety efforts, pharmacists play an essential role in leading change to optimize patient care. This includes collaborating with other disciplines, evaluating existing medication use processes, reviewing process metrics, and adopting solutions that reduce errors and increase patient safety.

Make Medication Safety Efforts Multidisciplinary

Like many processes in the hospital, the medication use process is a deeply integrated effort. For example, pharmacists will collaborate with pharmacy technicians during medication preparation and with providers on medication prescribing practices. Other groups involved in the medication use process may include nurses, specialists, and informaticists.

Collaborating with other disciplines and engaging leadership to support necessary change are critical to effectively leading medication safety efforts. This can be accomplished in a variety of ways. For example, a pharmacist may form a multidisciplinary subcommittee or task force within the hospital’s Pharmacy and Therapeutics Committee to dive deeper into insulin-related safety events that are occurring at the time of subcutaneous insulin administration to patients. The committee or task force can review patient safety metrics, develop and deploy a quality improvement (QI) initiative to reduce the insulin-related errors they’re seeing, then track and share the QI data with executive leadership.

Equip Pharmacy Teams to Lead Change Efforts

Medication safety presents a huge opportunity for pharmacists to leverage their expertise and elevate their role in improving patient care. This means pharmacy leaders should equip their teams with the skills and training necessary to identify opportunities for improvement and lead change within an organization. This might include education and training in QI processes, patient safety metrics, and change management. In addition, pharmacy leaders should help their team members identify key stakeholders, obtain executive-level support, and navigate what is often a complex health system.

Evaluate Existing Workflows and Technologies

To better understand where changes are needed, pharmacy teams should first evaluate existing workflows and technology used throughout the medication use process to identify gaps and areas where preventable medication errors are likely to occur. Assessing existing processes and reviewing their metrics can reveal important insights that highlight where improvements are needed. If patient safety metrics, like rates of hypoglycemia, are not currently being tracked, then this is a great place for pharmacy teams to start because you can't change what you can't measure. Once these processes are assessed and the data reviewed, pharmacy teams can start looking at solutions to address identified gaps and optimize areas where errors are likely.

One solution more pharmacy teams are looking to leverage in their health systems is technology. Technology’s role in preventing medication errors is well-documented.3 Technology such as clinical decision support software is an example of a high-leverage solution, a type of solution that hospitals should focus on implementing to reduce medication-related errors from high-alert medications, according to the Institute for Safe Medication Practices.4 Clinical decision support software can ease some of the burden on front line care teams by creating workflow efficiency, standardizing practice, and integrating with the electronic health record.

As an example, in the glycemic management space, clinical decision support software can give a significant boost to patient safety by standardizing how insulin is ordered, minimizing one-off insulin orders and unsafe prescribing practices. Additionally, this software utilizes sophisticated algorithms that consider patient-specific factors to optimize insulin dosing, replacing manual dosing calculations and one-size-fits-all protocols.

As pharmacy teams look to technology and other solutions to help reduce medication errors, having a clear understanding of the data around existing workflows and technology will be important for measuring the success of new medication safety initiatives.

Develop a Business Plan

Some medication safety efforts will require a great deal of planning, preparation, and buy-in, and may warrant a business plan to get approval. Once medication safety experts have aligned with the entire care team to determine areas for improvement in hospital workflows and technology tools, the data must be packaged into a concise business case for senior leadership that adequately communicates the impact of medication errors on costs and patient outcomes.

This business case should also entail the hospital’s potential patient outcome benefits and cost reduction after implementing the new proposed process or technology. By presenting information in this way, it makes it easy for decision makers to consume and connects the proposed work to organizational priorities.

In addition, the business plan should be multidisciplinary and incorporate the perspectives of clinical and technical resources who may be impacted by the work, including providers, nurses, pharmacists, and informaticists. Furthermore, the business plan should address how the proposed work will, at minimum:

  • Reduce medication error-related patient safety events
  • Change clinical and/or technical workflows
  • Affect other outcomes like length of stay
  • Impact operating costs

Following approval of the business plan, project leads will need to establish regular cadence with stakeholders and executive leadership to discuss barriers, review data, and share wins.

The Time is Now

As more national and public patient safety benchmarks raise the standard for high-alert medications like insulin, hospitals need to act now to establish plans to meet the new standards of care and reduce medication errors.

In support of the health care industry’s mission to deliver the highest standard of patient care, change needs to come from within each health system, and pharmacists are well-positioned to lead the charge when it comes to medication safety. By leveraging their expertise and experience in medication management and the medication use process, pharmacists can lead the implementation of new technologies, processes, and safety committees to reduce errors, improve care quality, and save lives.


1. Bates DW, Levine DM, Salmasian H, Syrowatka A, et al. The Safety of Inpatient Health Care. N Engl J Med 2023; 388:142-153. doi:10.1056/NEJMsa2206117

2. Patient Safety. World Health Organization. September 13, 2019. Accessed April 3, 2023.

3. Diabetes Technology Society Virtual Poster Meeting. Glytec. June 18, 2020. Accessed April 3, 2023.

4. Education is “predictably disappointing” and should never be relied upon alone to improve safety. Institute for Safe Medication Practices. June 4, 2020. Accessed April 3, 2023.

5. Three New Best Practices in the 2022-2023 Targeted Medication Safety Best Practices for Hospitals. Institute for Safe Medication Practices. February 10, 2022. Accessed April 3, 2023.

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