The Challenge

The safe use of medications is among the most complex and high-risk processes in healthcare. From prescribing through administration and monitoring, each step carries the potential for errors that could harm patients. Recognizing this risk, Nicklaus Children’s Hospital sought the expertise of the Institute for Safe Medication Practices (ISMP) to conduct a comprehensive review of its medication-use system.

Leadership sought a deep, systems-based assessment that would engage staff at every level, highlight vulnerabilities, and provide clear, actionable strategies to reduce risk and improve patient outcomes. David Mancuso, Executive Director, Pharmacy & Laboratory Services at Nicklaus Children’s, recalls, “There’s tremendous value when it comes to conducting a risk assessment — it helps evaluate how well we are mitigating risk, and that we have the right processes in place.”

The Assessment Process

ISMP partnered with Nicklaus Children’s to complete a Proactive Medication Safety Risk Assessment, consisting of:

Preparation and Document Review
ISMP set up a secure portal to exchange policies, order sets, and supporting materials. Reviewing these in advance allowed the team to identify focus areas and prepare for meaningful discussions on site.
Onsite Evaluation
A four-member ISMP team—including two pharmacists, a nurse, and a physician—visited the organization to observe practices firsthand. They shadowed workflows across inpatient and outpatient units, the ED, surgical and procedural suites, infusion centers, and pharmacy. Interviews with administrators, clinicians, and frontline staff provided a 360-degree view of the medication-use process. At the end of the visit, ISMP held an exit session to share initial findings, spark discussion, and build momentum for change.
Assessment Recommendations
ISMP synthesized its observations into a detailed set of strategic recommendations, highlighting both immediate improvements and long-term opportunities for transformation.

Key Findings and Opportunities

The assessment revealed strengths in staff commitment to safety, while also uncovering areas where processes could be reinforced. ISMP’s recommendations focused on building system reliability, staff engagement, and technology optimization.

The recommendations fell into the following categories:

Improvement of Medication Reconciliation
Strengthen the reliability of medication reconciliation at every transition of care, ensuring accurate medication histories and allergy information are consistently available.
Smarter Use of Technology
Optimize the electronic health record’s (EHR) clinical decision support, limit use of autoverification, and implement bidirectional smart infusion pump interoperability, reducing reliance on manual programming and minimizing the risk of dosing errors.
Standardization and Simplification
Stock the safest drug formulations (e.g., premixed solutions, smaller vial sizes), limit the use of custom intravenous fluids, and standardize oncology care protocols to improve accuracy, reduce variability, and protect staff and patients.
Stronger Safety Infrastructure
Expand the Medication Safety Program’s role as the driver of organizational safety initiatives and invest in additional pharmacy leadership dedicated to proactive risk management.
Staff and Patient Engagement
Provide targeted education for managers and frontline staff in error-prevention strategies and expand patient education led by pharmacists to support safe medication-use beyond the hospital stay.

Ensuring leadership stays informed is essential. Helen Lee, Medication Safety Officer at Nicklaus Children’s says, “we have monthly meetings with our senior VP, which is critical for securing resources needed to advance our projects — we’ve even been assigned an IT project manager to assist with project implementations.”

"Following the risk assessment, we created a five-year strategic plan and established clear accountability. Each initiative has an executive sponsor, a director, and a responsible lead, which has been critical for gaining leadership support and driving progress."

-David Mancuso, Nicklaus Children's

The Impact

Through this partnership, the organization has a clear roadmap for safer medication use. By addressing vulnerabilities in reconciliation, prescribing, dispensing, and administration, leaders can reduce harm events, improve reliability, and strengthen the culture of safety.

Perhaps most importantly, the process increased engagement and ownership among clinicians. ISMP’s collaborative, nonregulatory approach allowed staff to speak openly, share concerns, and contribute ideas. This collaborative spirit has already begun to shift the culture toward one where safety is shared, proactive, and deeply embedded into daily practice.

Looking Ahead

Nicklaus Children’s is now more than a year into implementing its strategic plan and already realizing the impact. Kristen Post, Medication Safety Manager at Nicklaus Children’s, proudly says, “through targeted improvements to our medication reconciliation process, admission Medication Reconciliation compliance has improved by 5 to 7 points and now consistently remains above 94%.”

As the team continues to execute on their plan, leadership and frontline staff are working together to:

Implement interoperability between smart pumps and the EHR
Expand pharmacy's role in medication reconciliation
Standardize chemotherapy safety practices
Strengthen oversight through a revitalized Medication Safety Council
Continue to optimize EHR functionality through expansion of decision support

The outcome is more than compliance or policy; it’s a systemwide commitment to patient safety. By partnering with ISMP, Nicklaus Children’s has laid the foundation for a safer future, where every medication order, dose, and administration is supported by reliable systems designed to protect patients.

"Before, we had a list of wishes and ideas but lacked a cohesive strategy. The report brought clarity and alignment and helped both us and leadership focus on key opportunities for improvement. That's when meaningful progress began."

- Gabriella Philipson, Medication Safety Officer at Nicklaus Children's