Recommendations for Senior Leadership to Advance Medication Safety

Each healthcare organization is supervised by a group of senior leaders.1,2 This executive team is tasked with many high-level responsibilities to ensure the continued operation of a healthcare organization.2 These responsibilities include determining the mission and vision, maintaining financial stability, and assessing the performance of upper-level directors and management as well as the organization in its entirety.2,3 Advancing the safety and quality of care provided to patients must be the leadership team’s top priority.4 By establishing and maintaining safety as a core value of the organization, senior leaders convey its significance to middle-level leaders (e.g., managers, directors), clinical leaders, and frontline employees, demonstrating a collective accountability all members of the organization have to achieve safe patient outcomes.1

Simply stating that safety is a core value of the organization is not enough to attain a safe and reliable environment. The core value of safety must be consistently demonstrated during everyday opportunities.5 When this safety commitment is consistently displayed by leadership at all levels at or above the level of opposing priorities, then the foundation for a culture of safety is built.1,5 A safe culture of reporting and a just culture of accountability are key elements to advancing medication safety because these can reduce the fear of punishment. 8 These reports can then be used as learning opportunities, and the focus is shifted to system solutions as the most effective safety strategy.4,5,9

The nature of medication safety improvement efforts often spans multiple healthcare disciplines, incorporates technology, and often requires human behavior change.1,4 Because of this, support from senior leadership is a key ingredient in the adoption and sustainment of safety initiatives.4 Leaders as safety advocates allow for the provision of time and resources necessary to drive system improvements, which ultimately reduces the risk for medication errors.


The National Coordinating Council for Medication Error Reporting and Prevention makes the following recommendations to senior leadership in healthcare organizations to advance medication safety:

  1. Institute and maintain a strong culture of safety and transparency by promoting psychological safety, eliminating intimidation tactics, and motivating staff, including leaders at all levels, to openly communicate and report system vulnerabilities, system failures, and medication-related events.3-5
  2. Model behaviors that align with a commitment to medication safety and a culture of safety during everyday opportunities.4,5
  3. Build and sustain a learning organization by promoting continuous learning from published best practices, and from both internal and externally reported medication- related events. Utilize systems thinking to foster innovative retrospective and proactive safety interventions.1,4
  4. Demonstrate and communicate medication safety as a core value by advocating for improvement initiatives designed to prevent harm from medication use and progress toward a culture of safety.1,4
  5. Establish and support a dedicated director-level position responsible and empowered to lead medication safety strategy and implementation is necessary (e.g., Medication Safety Officer) 6
  6. Provide the necessary human, informational, and financial resources to facilitate and drive safety initiatives within the medication use process.3,4
  7. Participate in leadership walk rounds regularly to identify and address barriers to patient safety and to create a direct line of communication between senior leadership and frontline workers.1,2,7
  8. Effectively communicate internal and external medication safety information to ensure staff awareness.1,3
  9. Proactively evaluate the medication use system, including processes, procedures, and technology, for vulnerabilities and prioritize improvement efforts to strengthen or eliminate these weak points.5
  10. Prospectively evaluate the effectiveness of the safety reporting systems using multidisciplinary quality improvement techniques to assure and maintain alignment with strategic goals, a just culture, and the collective accountability for improvement.


  1. Institute for Safe Medication Practices. Two effective initiatives for C-suite leaders to improve medication safety and the reliability of outcomes. ISMP Medication Safety Alert! 2017;22(6):1-5.
  2. Agency for Healthcare Research and Quality. Leadership role in improving safety. 2019. Available at: Accessed January 6, 2019.
  3. Schyve PM. Leadership in healthcare organizations: a guide to joint commission leadership standards. 2009. Available at: Accessed January 6, 2019.
  4. The Joint Commission. Comprehensive accreditation manual for hospitals: patient safety systems. 2018. Available at: Accessed January 6, 2019.
  5. The Joint Commission. The essential role of leadership in developing a safety culture. Sentinel Event Alert. 2017;1(57):1-8.
  6. Institute for Safe Medication Practices. A call to action: the case for medication safety officers (MSO). 2018. Available at: 08/MSOS%20White%20Paper_Final_080318_1.pdf. Accessed January 6, 2019.
  7. Institute for Healthcare Improvement. Patient safety leadership walkrounds. Available at: Accessed January 6, 2019
  8. Marx D. Patient Safety and the Just Culture: A Primer for Health Care Executives.New York, NY: Trustees of Columbia University; 2001.
  9. Just Culture: A Foundation for Balanced Accountability and Patient Safety. Philip Boysen, II OchsnerJ. Fall; 13(3) 400-406 Available at