Joint Statement from the American Society of Health-System Pharmacists (ASHP) and the American Pharmacists Association (APhA)

ASHP and APhA are deeply saddened by the reported harm experienced by Glenda Dorton and by the devastating impact this event has had on her family and loved ones. We also recognize that other patients were reportedly harmed, and our thoughts are with all those affected by this tragic event.

Medication errors that result in serious patient harm are devastating for patients, families, and healthcare professionals, and they underscore the importance of robust medication-use systems and a steadfast commitment to patient safety.

ASHP and APhA support a just culture approach that promotes transparency, reporting, learning, and accountability while recognizing that sustainable safety improvements come from identifying and addressing underlying system vulnerabilities rather than assigning individual blame before all contributing factors are understood. A culture of openness and continuous learning is essential to prevent future harm and strengthen the safety of medication-use systems. Our organizations also stand firmly against punitive actions that criminalize medication errors.

Pharmacists have a critical role in preventing medication errors and helping patients achieve optimal health outcomes. Working alongside physicians, nurses, technicians, and other members of the healthcare team, pharmacists are essential to designing, maintaining, and improving the safeguards that protect patients throughout the medication-use process.

No pharmacist, physician, nurse, technician, or other healthcare professional comes to work intending to harm a patient. When a serious patient safety event occurs, the effects often extend beyond the patients and families involved. Our organizations also recognize that those involved in the error may experience profound grief, emotional distress, and a lasting sense of responsibility. This second victim syndrome experience highlights the need to support healthcare professionals while remaining focused on accountability, learning, and improvement.

One of the most important ways to honor those harmed by medication errors is to learn from these events and strengthen the systems designed to prevent them. As a profession, we must remain committed to transparency, continuous quality improvement, and a culture that encourages reporting and learning. By doing so, we can advance medication safety and reduce the risk of similar tragedies occurring in the future.

For additional medication safety information and resources, visit the Institute for Safe Medication Practices.