Pharmacy Services

Pharmacy Services Residency

Medication Safety

 (PGY1 Elective Rotation)


Shantel Mullin, PharmD, BCPS

Site Description:

The University of Utah Hospitals & Clinics encompasses four hospitals, 14 retail pharmacies, and a multitude of clinics throughout the Salt Lake Valley. The primary site for this rotation is the University Hospital and the clinics 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 newborn ICU, surgery, and the emergency department.

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.

RLS Goals:

  • 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.


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.



Review 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.


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.


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


C, F

Complete a process audit or safety-related MUE. Present the results to staff with plans for related improvements if needed.


C, F

Create a newsletter article related to medication Safety


C, F

Discuss required readings how the information impacts practice


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

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 updated weekly. The resident is 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), and a midpoint and final evaluation that will be done in person and then recorded in PharmAcademic.

Updated April 2016