Pharmacy Services

Pharmacy Services Residency

Medication Safety

 (PGY1 Elective Rotation)


  • Shantel Mullin, PharmD, BCPS - Pharmacy Quality, Safety & Training Director
  • Other clinical and operational managers will be involved in topic discussions and evaluating resident projects during the month.

Site Description:

University of Utah Health (UUH) encompasses four hospitals, 15 retail pharmacies, and a multitude of clinics throughout the Salt Lake Valley. The primary site for this rotation is the UUH contained in the main hospital building. This hospital is a 488 bed, level 3 trauma center. The majority of patients are adults, though we also serve newborns, very-low birth weight neonates in an ICU, and pediatric patients in the Burn Unit. The pharmacy serves all locations in the hospital 24 hours a day with a USP 797-compliant IV center, CPOE order verification, and Automed scanning and dispensing, and barcode medication administration. Direct clinical pharmacy services are provided to all hospitalized patients for a minimum of 8 hours per day with expanded hours for acute care, critical care, newborn ICU, surgery, and the emergency department.

Role of the Preceptor:

The preceptor for this rotation directs the medication safety initiatives of the Department of Pharmacy Services for UUH. She is involved with coordinating responses to medication error reports throughout the UUH system. She is involved in participating in or identifying staff for involvement in RCAs and key interdisciplinary quality improvement projects for the organization. She is co-chair of the UUH Medication Safety Committee and Medication Error Review Committee. She participates in a wide range of committees including the system Patient Safety Committee and ADR sub-committee of P&T. She works on key medication safety initiatives in collaboration with managers and front line staff in pharmacy and outside of pharmacy.

Rotation Description:

This rotation is a reading, discussion, committee and project-based rotation. The resident will have opportunities to develop his or her understanding of medication safety issues in hospitals and clinics. Audits and projects will help the resident have a more clear understanding of their role in medication and patient safety in the health system.

Expectations of the Resident:

The resident is expected to be on time each day and for each assigned meeting. They need to use their time wisely to complete a variety of projects during the day. Residents may need to take readings home if they are unable to complete readings during the day. Residents are expected to “sign-post” on how their projects are coming along every week, flag out if they feel stuck in moving a project forward, and turn in drafts and final copies as agreed upon in the rotation calendar. Residents must maintain the confidentiality of patients and staff for each medication error reviewed or RCA that they participate in. Residents are expected to maintain a high level of professionalism in timeliness, dress and communication throughout the resident.

RLS Goals and Objectives:

R2.1 Demonstrate ability to manage formulary and medication-use processes, as applicable to the organization

R2.1.2 Participate in a medication-use evaluation
R2.1.3 Identify opportunities for improvement of the medication-use system
R2.1.4 Participate in medication event reporting and monitoring

R2.2 Demonstrate ability to evaluate and investigate practice, review data, and assimilate scientific evidence to improve patient care and/or the medication-use system

R2.2.1 Identify changes needed to improve patient care and/or the medication-use system
R2.2.2 Develop a plan to improve the patient care and/or the medication-use system
R2.2.4 Assess changes made to improve patient care or the medication-use system

R3.2 Demonstrate management skills

R3.2.2 Explain the elements of the pharmacy enterprise and their relationship to the health care system

R4.1 Provide effective medication and practice-related education to patients, caregivers, health care professionals, students, and the public (individuals and groups)

R4.1.3 Use effective written communication to disseminate knowledge

Activities Evaluated:

Rotation Activity RLS Goal Teaching Method
Attend System and Pharmacy Medication Safety Committees. Attend ADR Committee and report on pharmacist involvement in RL reporting & describe what can be done to prevent ADRs listed as “preventable”. (If ADR is not meeting during the rotation, a review of prior agendas will occur.) Attend other safety-related meetings as they arise. The resident will take notes and ask questions regarding key topics discussed in each meeting. R2.1.4
I, M
Complete and ISMP or related gap analysis. The resident will use interdisciplinary team resources, policies, and observation to determine our current state of practice. The resident will develop a recommendation for closing the gap, an owner, and a proposed deadline. ISMP gaps will be presented to System and Pharmacy Med Safety Committees. R2.2.1
C, F
Review and research several RLs per week as assigned. Enter manageable recommendations for improvements in the RL link with communication to the area managers. The resident and preceptor will discuss formal and informal networking opportunities. R2.1.4 I, C, F
Facilitate a root cause analysis (RCA) or common cause analysis (CCA) related to an RL or a problem-prone process identified in RL quarterly reports. R2.2.2
I, M, C, F
Complete a project related to process improvement. Determine if the process improvement will need a policy or SOP to be written or updated. Networking with nursing, physicians, other pharmacy departments, and Quality and Patient Safety staff will be necessary to complete projects R2.1.3
C, F
Complete a process audit or safety-related MUE. Present the results to staff with plans for related improvements if needed. R2.1.2
C, F
Create a newsletter article related to medication Safety that is evidence based and uses current literature. R4.1.3 C, F
Discuss required readings how the information impacts safe pharmacy practice R3.2.2 I, F
Teaching Methods include: I=direct instruction, M=modeling, C=coaching, and F=facilitation

Readings and Preparatory Work:

National Patient Safety Goals (NPSG)
Selected sections of To Err is Human
Selected chapters of Medication Safety: A Guide for Health Care Facilities
Selected chapters of Medication Safety Officer’s Handbook
Selected sections of ASHP Best Practices
Most recent 3 months of ISMP Inpatient Newsletter
Other readings will be assigned as related to med safety issues that arise on rotation

Project/Presentation Description:

See activities list above.

Typical Daily/Weekly/Monthly Activities:

Monday: Meet with preceptor of the week to discuss projects at 8:30AM.

Monday-Friday: The resident will then have time to read, plan projects, and execute the projects during the week. They will receive a list of meetings to attend at the beginning of the rotation, and this list will be updated weekly. The resident is HIGHLY encouraged to check in with the preceptor each morning to ask questions and ensure projects are on track.

Fridays at 3:30PM: The resident will summarize the work completed that week, review partial and final documents, discuss related topics or readings, plan projects for the coming week, and discuss progress and evaluations.


The resident will receive feedback through verbal discussions and evaluation of knowledge, skills and abilities. The resident will receive written edits on their written projects (formative), verbal feedback on their participation in committees and progress on projects (formative). A summative midpoint and final evaluation that will be completed in person and then recorded in PharmAcademic. The resident will evaluate the learning experience, preceptor and their progress on learning objectives at the end of the rotation.

Updated September 2017