Bethesda, Maryland, USA August 21, 2026
The American Society of Health-System Pharmacists (ASHP) and the American Pharmacists Association (APhA) have issued a joint statement emphasizing the importance of medication safety, transparency, and system-wide learning following reports of serious patient harm associated with medication errors. The organizations expressed sympathy for Glenda Dorton and her family and acknowledged that other patients were reportedly affected. Their statement focuses on strengthening medication-use systems while supporting healthcare professionals involved in safety events. ASHP and APhA emphasized that preventing future harm requires healthcare organizations to identify underlying system vulnerabilities, encourage reporting, and establish a culture of continuous improvement rather than relying primarily on individual blame. The organizations also reiterated their opposition to punitive approaches that criminalize medication errors.
Just Culture Supports Medication Safety Improvements
ASHP and APhA highlighted the importance of a just culture approach to medication safety. This framework emphasizes transparency, reporting, learning, and appropriate accountability while recognizing that serious medication errors can arise from multiple interacting weaknesses within healthcare systems. According to the organizations, sustainable safety improvements depend on understanding the factors that contribute to an event before assigning responsibility to an individual healthcare professional. A culture of openness and continuous learning can encourage professionals to report safety concerns, allowing healthcare institutions to identify vulnerabilities and implement safeguards before similar events occur. The organizations also stressed that medication errors can have profound consequences for patients, families, and healthcare professionals. Serious safety incidents may create emotional distress and a lasting sense of responsibility among clinicians involved in an error. ASHP and APhA referred to this as the “second victim” experience, emphasizing that healthcare professionals may also require support after a serious patient safety event. Addressing this impact while maintaining accountability and focusing on system improvement is an important component of a comprehensive medication-safety strategy.
Pharmacists Play Key Role in Preventing Errors
The joint statement emphasized the central role of pharmacists in medication safety and patient care. Pharmacists work alongside physicians, nurses, pharmacy technicians, and other healthcare professionals throughout the medication-use process. Their responsibilities can include helping design medication safeguards, supporting appropriate medication use, identifying potential errors, and contributing to continuous quality-improvement initiatives. ASHP and APhA stated that no pharmacist, physician, nurse, technician, or other healthcare professional goes to work intending to harm a patient. The organizations therefore emphasized the need for healthcare systems to examine how processes, communication, technology, workflows, and other contributing factors may influence medication safety. By strengthening these systems, healthcare organizations can reduce opportunities for preventable errors while supporting healthcare professionals in delivering safe and effective care.The organizations’ position also places continuous quality improvement at the center of medication-safety efforts. Rather than treating an individual error as an isolated event, healthcare organizations can use safety incidents as opportunities to identify weaknesses and develop stronger safeguards. Reporting mechanisms, transparent investigations, professional education, and ongoing evaluation can help create systems that are more resilient to human error.
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Transparency and Learning Remain Essential
ASHP and APhA stated that one of the most meaningful ways to honor patients and families affected by medication errors is to learn from safety events and strengthen the systems designed to prevent recurrence. The organizations called for continued commitment to transparency, reporting, accountability, and quality improvement across the medication-use process.The statement reinforces the broader importance of patient safety in pharmacy practice and healthcare delivery. Medication management involves multiple professionals and stages, meaning effective safety strategies require collaboration across the healthcare team. Strengthening communication and safeguards throughout this process can help reduce the risk of similar events and improve patient outcomes. ASHP represents more than 65,000 pharmacy professionals, including pharmacists, student pharmacists, and pharmacy technicians across healthcare settings, while APhA represents the broader pharmacy profession and supports pharmacists, student pharmacists, and pharmacy technicians. Through their joint statement, the organizations have highlighted the need for a balanced approach that combines patient protection, professional support, transparency, and system-level accountability to advance medication safety.
Source: ASHP, APhA press relese
