Medication Safety APPE

The Medication Safety rotation is a one-month rotation designed to provide students with a broad perspective of medication safety topics and activities in a health-system. It will build on the student’s basic clinical knowledge and understanding of pharmacy operations and will enhance the student’s critical thinking skills.

The rotation is designed to expose students to medication safety nomenclature, key principles, tools, and available resources. The student will participate in several activities designed to improve the student’s working knowledge and experience with medication safety concepts. At the end of this rotation the student will be able to apply knowledge in any pharmacy practice setting to improve medication safety for patients.

The Medication Safety Team (MST) at Saint Luke’s Hospital is a multidisciplinary group of pharmacists, nurses, and physicians who represent bedside clinicians, pharmacy operations and management, quality, risk management, nursing management, and nursing education. A subgroup of the committee (including pharmacy residents) meets biweekly to review recent medication incidents, discuss trends in error reporting, evaluate ISMP alerts, and determine items to discuss at the Saint Luke’s Hospital MST monthly meeting. MST serves to provide expertise and leadership in medication safety and provide recommendations for improvements in medication use systems and staff education to the system medication safety committee/pharmacy leadership, Nurse Practice Councils, and any other appropriate committees. The student may be expected to actively participate in the monthly MST meetings by providing medication safety pearls and leading the discussion on assigned projects.

In addition to the MST meeting, the student will be assigned various projects throughout the rotation and will be responsible for updating the preceptors and the committee on their progress, and presenting their final recommendations within the department, committee, or organization, as appropriate.

Goals and Objectives

The preceptor and student will meet at the start of the rotation to discuss and settle on individualized goals and objectives for the rotation. The following are a list of potential goals and objectives:

  • Develop an understanding of the systems-based approach to improving medication-use safety.
  • Explain why error reporting is so vital to improving medication safety. Describe types of error reporting systems that exist. Describe the NCC-MERP medication error classification schema. Explain methods used to investigate and analyze root causes of medication errors, how to develop effective risk reduction strategies, and how to prioritize action items. Participate in the institution’s error tracking system. Describe how errors are reported, investigated, and resolved. Explain the quality improvement process associated with identified errors.
  • Describe methods to identify organizational medication safety risk (e.g., self-assessments, error reports, trigger methodology). Identify risk reduction strategies and delineate effectiveness of various strategies.
  • Explain why certain medications are termed “high alert medications.” Describe risk reduction strategies that can be used to prevent harm from high-alert medications and other medications.
  • Summarize Joint Commission National Patient Safety Goals (NPSGs) designed to improve medication-use safety, such as NPSG 3.
  • Describe methods and tools, such as Root Cause Analysis (RCA), Failure Modes and Effects Analysis (FMEA), and Lean Sigma, used to improve medication safety.
  • Describe the concept of “Culture of Safety.” Compare and contrast punitive, blame-free, and just cultures.
  • Describe select technologies that are employed to improve medication-use safety. Discuss the benefits and pitfalls of these technologies.
  • Compare medication safety resources, such as the Institute for Safe Medication Practices (ISMP), American Society for Heath-Systems Pharmacists (ASHP), Agency for Healthcare Research and Quality (AHRQ), and the Institute for Healthcare Improvement (IHI).



Jeannette Ploetz, PharmD, BCPS, BCCCP, DPLA, FCCM
  • School of pharmacy: University of Kansas
  • Residency training: PGY1—The Johns Hopkins Hospital ; PGY2 Critical Care - The Johns Hopkins Hospital
  • Specialty interests: Medication Safety, Medical Critical Care, Infectious Disease
  • Health system, hospital, pharmacy, and residency committee involvement: Chair, Saint Luke’s Hospital Medication Safety; Chair, Saint Luke’s Health System (SLHS) Medication Safety; Chair, SLHS Heparin PI Team; Member, SLHS Medication Safety Council, SLHS Coordinating Council, SLHS Critical Care Practice Council, SLHS COVID Clinical Taskforce
  • Professional involvement: Society of Critical Care Medicine (SCCM), CPP Medication Safety; SCCM, Item Writing Committee; SCCM, Drug Shortage Committee; Kansas Council of Health-System Pharmacy (KCHP) Education Committee; American Society of Health System Pharmacists (ASHP)
  • Pharmacy awards, accolades: 2011 Preceptor of the Year; 2019 Resident Recognition Award; 2021 SCCM Presidential Citation