Minimize Distractions in the Clinical Setting

Minimize Distractions in the Clinical Setting Cover Image

Chuck DiTrapano, RPh and Bailey Klingaman discuss the dangers of distractions and interruptions in the clinical setting, and provide numerous solutions to help reduce the risk of harmful medication errors and improve patient safety. Anyone who has worked in any healthcare setting can attest to what the Institute for Safe Medication Practices (ISMP) and others […]

Making Medication Administration Safer

Making Medication Administration Safer Cover Image

Eric Cropp, RPh, shares his personal story about a medication error that forever changed his life, how he became a patient safety advocate, and ways we can make medication administration safer for patients and caregivers. What Happened to Emily Jerry There were multiple red flags leading up to Emily Jerry’s last treatment. The first came […]

Pharmacy Technicians: The Invisible Asset

Pharmacy Technicians: The Invisible Asset Cover Image

If you have ever had a prescription filled in a pharmacy, received an IV infusion in a hospital, or received a medication in a nursing home, you have received services from a pharmacy technician. Who are these people? How are they trained? The answer to these questions is both complex and inconsistent but can be […]

The Vital Role of Pharmacy Technicians

Two-year-old Emily Jerry looking up.

The following post was written by Chris Jerry of the Emily Jerry Foundation. Chris tragically lost his daughter as a result of a preventable medical error made by a pharmacy technician. We are grateful to Chris for his courage in sharing his story as well as for the work he is doing to bring light […]

Minimizing Risk with Standardized IV Care for the Infusion Center

Minimizing Risk with Standardized IV Care for the Infusion Center Cover Image

In recent years there has been a plethora of new infusion and injection therapies flooding the healthcare market. These new therapies are giving patients with chronic illnesses a broader range of treatment options and providing them the opportunity to live their lives with fewer debilitating chronic symptoms. As an Infusion Center Nurse Manager, with over […]

Safety and Standardization in Labeling and Repackaging

Safety and Standardization in Labeling and Repackaging Cover Image

Packaging and labeling are believed to be the cause of 33% of medication errors and poor label design is cited as a potential cause. In 2016, the FDA released guidelines for safe labeling and repackaging acknowledging that improper repackaging of drug products can cause serious adverse events stating, “Because labeling, packaging, and nomenclature have been […]

Pharmacy IV Rooms: Are we minding the gap…???

Pharmacy IV Rooms: Are we minding the gap...??? Cover Image

Thank you to Rayburn Vrabel, former President and Principal Consultant at Vrabel Consulting Inc., and current Medication Systems Strategy Advisor, for allowing RxToolKit to publish his article, as originally seen on LinkedIn May 15, 2015, about the systems and practices that affect IV room safety. Last week in Mark Neuenschwander’s Point of Care Forum (, […]

In Support of the Second Victim

In Support of the Second Victim Cover Image

Eight years after the tragic medication error that led to two-year-old Emily Jerry’s death, Eric Cropp, RPh is still distraught over the events of that day. He currently advocates for patients and caregivers involved in medication errors, and supports second-victim awareness. It has been 8 years since I made the biggest mistake of my life. […]

Insulin: One Patient – One Pen

Insulin: One Patient - One Pen Cover Image

“Health care has safety and quality problems because it relies on outmoded systems of work. Poor designs set the workforce up to fail, regardless of how hard they try. If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative […]

Medication Errors: “A Pharmacist’s Tale”

Medication Errors: "A Pharmacist's Tale" Cover Image

JDJ Consulting Founder and President John Karwoski discusses a recent near-miss medication error and the actions he took to rectify the situation. He also provides suggestions for ways to prevent medication errors and near-misses in the future. I was working at the hospital last night and caught a “near-miss.” The physician ordered a 4000 unit […]