Medication Safety Committee

(Front row from left) Milena Wong; Alyssia Jaume; Amy Rosenberg, Pharm.D.; Erica Ledford, Pharm.D.; Betsy Dodd, Pharm.D.; Jim McAllister, Pharm.D., M.S.; and Charles Crescioni, R.N.


By Amy F. Rosenberg, Pharm.D.

Serious medication errors happen frequently in hospitals across the country — and they can happen in our hospital as well. The Shands at the University of Florida Medication Safety Committee continuously evaluates medication systems and practices with the primary goal of preventing patient harm due to medication errors.

The interdisciplinary committee is made up of nurses, pharmacists, physicians, respiratory therapists, risk managers and quality improvement professionals. The membership comprises those practicing in adult and pediatric areas at Shands at UF, Shands Cancer Hospital, Shands Vista and Shands Rehab Hospital and includes UF Physicians representatives.

Each month, the committee reviews medication-related patient safety events. Following review, the team makes recommendations for future prevention of similar errors. In addition to medication errors that occur in our facilities, the committee regularly reviews published reports of medication-related errors at other hospitals and implements recommended safeguards to prevent those mistakes from happening here.

High Alert Medications

A particular area of focus for the Medication Safety Committee is on the prescribing, dispensing and administration of High Alert medications, which are medications that can cause serious harm to a patient if an error occurs. Examples of High Alert medications are insulin and anticoagulant medications, such as heparin or warfarin. With input from members of the Medication Safety Committee, two important policies were developed related to the use of High Alert medications: the High Alert Medication policy and the High Alert Medication Verification policy.

The High Alert Medication policy (Pharmacy Policy 09-07) defines safeguards in place throughout the hospital for each of our official High Alert medications. The High Alert Medication Verification Policy (Nursing Policy MA-014) details the process that requires two health care professionals, usually two nurses, to verify particular High Alert medications before administering the medication to a patient. The committee frequently examines and recommends updates to these policies. Additionally, the Medication Safety Committee has oversight of the Look-Alike Sound-Alike medications and the strategies in place to prevent Look-Alike Sound-Alike medication errors.

The recent implementation of Epic provides
many possibilities for enhanced medication safety in
prescribing, dispensing and administering medications.

A goal for the committee in 2011 will be to assist in maximizing medication safety features within the Epic system. The committee meets on the third Thursday of every month, and we welcome suggestions for additional methods of medication error prevention. If you have an idea for preventing medication errors, please email Amy Rosenberg at