Patient Safety: The Key Role of the Clinical Pharmacist

By Brittany Duke, Pharm.D., ORISE Fellow, Division of Health Care Quality, Office of Disease Prevention and Health Promotion

shutterstock_80921569A surprising 30 percent of drug prescriptions are never filled and up to 50 percent are not continued as prescribed, especially after the first six months. National Patient Safety Awareness Week (March 13-19, 2016) provides an opportunity to highlight the unique role of clinical pharmacists in improving patient safety by ensuring that patients understand how to take their medication as prescribed. By improving patients’ medication adherence, clinical pharmacists help prevent adverse drug events (ADEs) that are the result of patients not taking medication as prescribed.

Over the past 20 years, clinical pharmacists have developed patient safety strategies and have played a leading role in their implementation. The clinical pharmacist’s role is to make sure patients understand and adhere to their medication regimen with respect to timing, dosage, and frequency during the prescribed length of time. In addition, the clinical pharmacist prevents ADEs by providing drug information in plain language to the patient at key transition times, such as hospital admission and, discharge, as well as during the patient’s entire stay. The clinical pharmacist assures that the patient is taking their medications as prescribed, monitors for adverse effects and lack of adherence, and helps with early identification of issues that may compromise patient safety.

For example, clinical pharmacists reduce the rate of drug-related problems when patients are admitted to the hospital through medication reconciliation by developing a complete list of medications that a patient is taking. Clinical pharmacists also present medication information and assess patient understanding when the patient is discharged.

By working with patients both as they are admitted and discharged and applying the principles of health literacy to ensure that patients understand how to take their medications, clinical pharmacists detect and resolve potential issues that could lead to ADEs and help build a foundation for patient safety.

One patient safety strategy that clinical pharmacists use is the “SIMPLE” plan which focuses on communication skills, cultural sensitivity, and patient-centered care.

  • S – Simplify the regimen (e.g., adjust the timing, dosage, or frequency of medication to make it easier to follow)
  • I – Impart knowledge (e.g., distribute written information about the medication and/or health condition)
  • M – Modify patient beliefs and behaviors (e.g., assess benefits and barriers to adherence)
  • P – Provide communication and trust (e.g., actively listen to the patient)
  • L – Leave the bias (e.g., tailor the education to the patient’s level of understanding)
  • E – Evaluate adherence (e.g., follow up with patients to make sure they are taking their medication)

Collaboration of interdisciplinary health care providers that include clinical pharmacists is an evidence-based approach to improving medication adherence and, subsequently, to preventing ADEs. Evidence-based approaches to preventing ADEs are a key component of the National Action Plan for Adverse Drug Event Prevention, developed by the Office of Disease Prevention and Health Promotion (ODPHP). The ADE Action Plan can be used by health care professionals, policymakers, public and private sector organizations, and communities to organize and take action toward preventing ADEs.

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