Clinical pharmacy and patient safety: Have we reached a golden era?

Physicians, nurses, and pharmacists are trained to be careful and to function at a high level of proficiency …It is curious, therefore, that high error rates have not stimulated more concern and efforts at error prevention. One reason may be a lack of awareness of the severity of the problem. Hospital-acquired injuries are not reported in the newspapers like jumbo-jet crashes, for the simple reason that they occur one at a time in 5000 different locations across the country. Twenty-five years ago, publication of The Institute of Medicine's To Err is Human2 was a watershed moment for the US healthcare system, as it broke the silence around medical errors and their consequences. The report was a wake-up call to all healthcare professions, marking the beginning of a new era of accountability within healthcare, and spawning much needed focus on systems-based initiatives to not only reduce preventable errors but to also re-engineer the healthcare system to improve overall patient safety. The problem was "…not bad people in health care—it is that good people are working in bad systems that need to be made safer."2 In the years following To Err is Human, funding opportunities allowing for research specifically focused in patient safety greatly expanded our knowledge of not only where the problems existed, but their potential solutions as well. Medication errors have far too often been common causes of patient harm,3 and the wake-up call that was To Err is Human not only challenged the profession of pharmacy to ensure safe use of medications but also provided empowering opportunities for clinical pharmacy to evolve and demonstrate its ability to insure the safe and effective use of medications. Pharmacy answered this call, from early studies documenting clinical pharmacists' ability to reduce adverse events through participation on inpatient rounds to leading efforts in medication barcoding, computerized order entry, automated drug dispensing, and integration of clinical decision support.4-8 In this themed issue focused on Clinical Pharmacy and Patient Safety, we are pleased to publish a diverse selection of papers that continue to highlight the roles and opportunities for clinical pharmacists to enhance patient safety. They include papers focused on medication safety during transitions of care, medication stewardship programs designed to enhance patient safety, integration of pharmacogenomics into the care process to personalize medication selection, the use of novel computer-based decision support tools to avoid medication harm, and an examination of the safety and efficacy of artificial intelligence (AI) to provide medication information for patients. The future longevity of our profession relies on both adaptability and increased proactiveness to respond to an ever-changing, and often unpredictable, healthcare environment. These latest challenges to patient safety should also be viewed as potential opportunities for clinical pharmacists to develop and refine innovative tools and approaches needed in response. Prioritizing patient safety undoubtedly will require commitment of additional resources within health systems to expand patient safety infrastructure, as well as pharmacists willing to challenge the status quo. And with each step, partnering with sound research to critically examine the gaps and their solutions and an increasing reliance on implementation science to assist the scaling up of evidence-based best practices that are determined will be needed. Just as clinical pharmacy responded to the call from To Err is Human, let us hope that our profession continues to adapt to new challenges in patient safety, and leads the initiatives that will hopefully arrive us closer to achieving a "Golden Era" in patient safety. Drs. Ernst and Fravel are members of the JACCP editorial board. The authors declare no conflicts of interest.