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Medication Safety Considerations Home Study

“First, do not harm.” This phrase is well known to health care providers. The Institute of Medicine’s landmark report, “To Err is Human: Building a Safer Health System,” brought to light the number of Americans who die each year from medical mistakes. Due to the tremendous media attention, the public demand for safety improvements resulted and medication safety became an important responsibility of pharmacists. While many changes in processes and technology have reduced the number of medication errors, errors still occur.
In March of 2017, the World Health Organization (WHO) launched a global initiative to reduce medication errors by 50% in all countries by the year 2022.1 The Global Patient Safety Challenges on Medication Safety, “Medication Without Harm” serves to address the weakness in health care systems that can lead to medication errors. According to the WHO website, “medication errors cause at least one death every day and injure approximately 1.3 million people annually in the United States alone.” “Globally, the cost associated with medication errors has been estimated at US$ 42 billion annually or almost 1% of total global health expenditure.” 1
Medication Safety is a topic that all pharmacists need to be informed of in order to prevent medication errors. While much of the literature may seem to focus on inpatient/hospital/institutional settings, all areas of pharmacy practice have the opportunity to improve safety and ultimately the health outcomes of our patients. Some pharmacists may not be aware that the tools used in the hospital setting may be used in the community/ambulatory setting as well as to help analyze medication errors and establish processes to prevent errors in the future.  Understanding how human errors and choices impact patient safety can help establish a just culture that balances individual accountability and organizational responsibility for improving processes.2,3 Including patients in medication safety discussions is a new approach to understand better what is important to our patients and how we can educate them on safe medication use.4
  2. Boysen, PG. Just Culture: A Foundation for Balanced Accountability and Patient Safety. The Ochsner Journal. 2013;13:400-406.
  3. Rogers E, Griffin E, Carnie W, Melucci J, Weber RJ. A Just Culture Approach to Managing Medication Errors. Hosp Pharm. 2017;52 (4):308-315. doi:10.1310/hpj5204-308.
  4. Lee JL, Dy SM, Gurses AP, Kim JM, Suarez-Cuervo C, Berger ZD, Brown R, Xiao Y. Towards a More Patient-Centered Approach to Medication Safety. Journal of Patient Experience. 2018;5(2):83-87. DOI: 10.1177/2374373517727532.



CE Hours


CE Units


Activity Type

  • Knowledge

Target Audience(s)

  • Pharmacist


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Accreditation Council for Pharmacy Education

Requirements for CE Credit

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  • 1. Human Factors impact medication errors
  • 2. Evaluate ways to Define terminology associated with medication safety
  • 3. Describe Just Culture and its role in managing medication errors
  • 4. Explain how reduce medication errors at transitions of care
  • 5. Investigate ways to develop a patient-centered approach to medication safety


Brenda Pahl, PhD
Director of Experiential Progams, Cedarville University School of Pharmacy

Brief Bio : Dr. Pahl received her Bachelor of Science in Pharmacy degree from Ohio Northern University and her Doctor of Pharmacy degree from The Ohio State University.  Prior to her academic appointment at Cedarville University in 2015, Dr. Pahl served as a practicing pharmacist for over 20 years. Her experience in areas of pharmacy practice include hospital/acute care practice, pharmacy management, long term care, ambulatory care (anticoagulation) and community practice. She has also served as a preceptor for advanced pharmacy practice experience students. Dr. Pahl’s current clinical practice site focuses on trauma/emergency/acute care and medication reconciliation. She also serves as the Director of Experiential Programs.

Activity Number


Release Date: May 23, 2019
Credit Expiration Date: May 23, 2022