The intersection of medication management and patient safety

Clearway Health's Holly Herring, PharmD, regional director of specialty pharmacy operations, was recently interviewed by HCPro to explain why hospital safety leaders must view medication safety as a system wide responsibility. In this discussion, she highlights practical steps to elevate medication management as a shared priority, from preventing drug diversion to improving patient education and ensuring safe, timely access to specialty medications.

Here is a summary of Holly's Q&A discussion with HCPro's Patient Safety Monitor.

Q: How can hospital patient safety leaders help elevate medication management as a sharedresponsibility across clinical teams?

Herring: Medication management is a systemwide safety issue that spans every stage of care, from prescribing and administration to monitoring and reconciliation, and is not solely a pharmacy responsibility. Hospital safety leaders intentionally include medication safety within the organization’s broader patient safety strategy. For example, as a regular topic in safety huddles, interdisciplinary rounds, and performance improvement meetings. When physicians, nurses, and pharmacists engage together in these discussions, they begin to recognize how their individual actions connect to shared safety outcomes. This builds a culture of collective accountability and continuous improvement.

Hospitals also need to think beyond traditional definitions of medication safety and management. Not all safety threats are captured in adverse drug event reports or medication error logs. Issues such as drug diversion are often overlooked and pose significant risks to both patients and staff. in fact, drug diversion prevention should be fully integrated into hospital medication safety initiatives and elevated as a core patient safety priority. This interdisciplinary approach strengthens controls over controlled substances and deepens the overall culture of safety and accountability.

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Q: What patient safety risks arise when specialty medications are introduced into hospital or ambulatory workflows?

Herring: Specialty medications present significant safety challenges because of their complex dosing, administration, monitoring, and specific storage and handling requirements. These risks are especially heightened in the outpatient setting, where medication safety oversight and clinical team involvement are often limited, making it more likely for errors to occur once the medication leaves the pharmacy. Evidence consistently shows that when a pharmacist is actively involved between the medication and the patient, outcomes improve and the risk of harm decreases.

Pharmacies should establish structured processes for patient counseling and consider offering a 24/7 hotline for access to specialty pharmacists who can address urgent questions and concerns.The Utilization Review Accreditation Commission (URAC) and the Accreditation Commission for Health Care (ACHC) are the two most sought-after [accreditors] demonstrating a seal of quality for pharmacy operations and patient management services. Pharmacies should also prioritize specialty pharmacy accreditation to help reduce these risks by ensuring organizations meet rigorous standards for medication handling, patient education, documentation, and care coordination. Accreditation frameworks promote consistency, accountability, and quality assurance, strengthening the safety infrastructure around specialty medication use.

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Q: What role should patient safety teams play in ensuring that education around specialty medications is consistent, comprehensible, and documented?

Herring: Specialty medications are complex, and its important for patients to understand how to take them, recognize side effects, and stay adherent to therapy. When education is inconsistent or unclear, it becomes a leading cause of noncompliance and safety events.

Patient safety teams should collaborate with pharmacy, nursing, and providers to create standardized education protocols so that every patient receives the same clear information about medication purpose, administration, and what to do if problems arise. Hospitals and pharmacies should also understand their patient population, including common second languages, and promote health literacy by using plain language and culturally appropriate materials to confirm comprehension. Education should be consistently documented in the clinical record to support continuity of care and identify opportunities for improvement.