When I asked ACCP Practice and Research Network (PRN) leaders to share examples of how their members are advancing my presidential theme of preventable medication harm, I expected to receive individual stories, projects, publications, member examples, or programs that could be highlighted in a future column.

What I received was something more powerful. I received a mosaic.

Across PRNs, leaders shared examples of member-driven work spanning nearly every point where clinical pharmacists help keep patients safe. Adult Medicine highlighted medication reconciliation, transitions of care, and antithrombotic stewardship. Ambulatory Care described preventing severe hypoglycemia through continuous glucose monitoring and glucagon. Cardiology pointed to work involving heart failure therapy access, atrial fibrillation quality improvement, anticoagulation optimization, and venous thromboembolism treatment. Community-Based and Endocrine and Metabolism described harm-prevention efforts related to buprenorphine access, adverse drug event awareness, and anabolic-androgenic steroid misuse. Critical Care highlighted complex pharmacotherapy education and evidence synthesis. Drug Information connected artificial intelligence, drug information, and health equity. Emergency Medicine emphasized clinical pharmacist presence in high-risk emergency care environments. Nephrology highlighted nephrotoxin stewardship and race-free kidney function estimation for medication-related decision-making. Pediatrics identified safety issues related to creatinine clearance calculations, tramadol use, intravenous promethazine therapy, and vitamin A treatment in patients with measles. Pharmaceutical Industry described pharmacovigilance, health economics and outcomes research, medical affairs activities, and postmarketing safety work. Pharmacokinetics/Pharmacodynamics/Pharmacogenomics highlighted genotype-guided prescribing, and Transplant described work connected to race-free eGFR equations, drug dosing, and transplant pharmacy research.

The breadth of these examples matters. It reminds us that preventable medication harm is not confined to one practice setting, one disease state, one PRN, or one type of clinical pharmacist intervention. It is not only an emergency department issue, a critical care issue, an ambulatory care issue, a nephrology issue, or a pediatric issue. It is a shared professional purpose.

And perhaps most importantly, it is already embedded in the work ACCP members are doing every day. As I read these examples, three themes emerged. ACCP members are preventing medication harm by improving the quality of medication decisions, being present in the places where medication risk is highest, and building the evidence, education, and tools that help others practice more safely. These themes are not separate silos; they overlap and reinforce one another. Together, they show how clinical pharmacists prevent harm at the patient level, the practice level, and the health system level.

Preventing Harm through Safer Medication Decisions

One of the clearest examples comes from the paper, “Adopting Race-Free Estimated Glomerular Filtration Rate for Unifying Medication-Related Decision-Making: An Opinion Paper of the Nephrology Practice and Research Network of the American College of Clinical Pharmacy.” The paper calls for the adoption of race-free, body surface area-adjusted estimated glomerular filtration rate for medication-related decision-making and urges coordinated change across health systems, clinical decision support programs, institutional protocols, pharmacy curricula, and regulations.¹

This is exactly the kind of upstream work that can prevent medication harm before it reaches the patient. Kidney function estimation influences drug selection, dosing, monitoring, toxicity risk, and therapeutic access. When the tools we use to estimate kidney function vary across practice settings, or when they carry assumptions that may contribute to inequity, medication-related decisions become less consistent and potentially less safe. The Nephrology PRN’s work helps highlight the fact that preventing harm is not only about catching an error at the bedside. It is also about questioning the assumptions embedded in our systems, equations, protocols, and educational models.

What is especially meaningful is that this work produced more than a single publication. It prompted scholarly dialogue in JACCP, including multiple commentaries and a reply from the Nephrology PRN authors.^2-6 That exchange matters because it demonstrates what clinical pharmacists do to prevent harm: examine evidence carefully, challenge assumptions respectfully, and work through complex medication-related questions in ways that strengthen practice.

The cross-PRN engagement around this topic also reminds us that medication safety problems rarely fit neatly into one specialty. Kidney function estimation affects decisions in adult medicine, ambulatory care, critical care, transplantation, and many other areas of practice. When one PRN raises an important question, the impact can ripple across the College.

Other PRNs shared additional examples of safer medication decision-making. The Pharmacokinetics/Pharmacodynamics/Pharmacogenomics PRN highlighted education related to genotype-guided hydralazine dosing, including recommendations intended to improve efficacy in rapid and intermediate NAT2 metabolizers. The Pediatrics PRN identified discussions around creatinine clearance calculations in the electronic health record, tramadol safety, avoidance or restriction of intravenous promethazine, and strategies for optimizing vitamin A administration in patients with confirmed measles. These examples differ in content, but the underlying message is the same: clinical pharmacists prevent harm by improving the quality of medication decisions before those decisions reach patients.

Preventing Harm through Clinical Pharmacist Presence and Care Transitions

Several PRNs also reminded us that preventable medication harm often occurs when care is fragmented, transitions are rushed, or clinical pharmacist expertise is absent from high-risk environments.

The Adult Medicine PRN highlighted the RxCARES program at the University of Illinois-Chicago, a pharmacy student–driven initiative targeting high-risk patients for medication reconciliation and transitions of care. Students complete comprehensive medication histories, assist with admission and discharge reconciliation, identify discrepancies, communicate with the medical team, and conduct follow-up phone calls after discharge. That is harm prevention in one of its most practical forms. Transitions of care are filled with risk: incomplete histories, discontinued therapies, duplicate medications, unclear instructions, access barriers, and delays in follow-up. When pharmacists and pharmacy learners are embedded in these processes, they help close gaps that patients may never know existed but that could have harmed them.

The Ambulatory Care PRN offered another patient-centered example: identifying a patient with diabetes using insulin therapy who was experiencing frequent severe hypoglycemia. By prescribing continuous glucose monitoring and glucagon, clinicians were able to identify and treat future episodes earlier and more effectively. This example is powerful because it translates “medication optimization” into something patients immediately understand: preventing a dangerous low blood sugar event.

The Emergency Medicine PRN, which I have highlighted previously for its work around clinical pharmacist presence in the emergency department and the television show, The Pitt, continues to model how our members make invisible safety work visible. Their message is direct: when clinical pharmacists are absent from high-risk care settings, opportunities to prevent medication harm may be missed. That principle extends far beyond the emergency medicine setting.

Patients may not always see the clinical pharmacist who prevents the unsafe dose, identifies the interaction, questions the anticoagulation plan, adjusts therapy for kidney function, or ensures a high-risk medication is monitored appropriately. But the absence of harm does not mean there’s an absence of impact. In fact, it often means the clinical pharmacist’s work succeeded. That is the paradox of our profession: some of our most important contributions are the crises that never happen.

Preventing Harm through Evidence, Education, and Shared Tools

PRN leaders also shared examples showing that preventing medication harm is not just accomplished through direct patient care. It also occurs through scholarship, education, evidence synthesis, and shared tools that help pharmacists practice more safely.

The Critical Care PRN described a sustained effort to provide continuing education on increasingly complex pharmacotherapy in critical illness. Their programming has educated nearly 1000 pharmacists over the past two years. That reach is important. In high-acuity environments, harm prevention depends on clinicians who can manage complex regimens, evaluate emerging evidence, and respond to rapidly changing patient conditions. The Critical Care PRN also highlighted a recently published paper in Pharmacotherapy titled, “Pharmacotherapeutic Controversies During Temperature Control After Out-of-Hospital Cardiac Arrest: A Semi-Structured Literature Review.”⁷ This type of scholarship matters because uncertainty is one of the places where medication harm can emerge. When evidence is complex, evolving, or difficult to apply at the bedside, clinical pharmacists help translate these ambiguities into safer therapeutic decisions.

The Drug Information PRN provides another important example. Its opinion paper on the responsible use of artificial intelligence in health care addresses one of the most important emerging safety issues in contemporary practice.⁸ Artificial intelligence will increasingly influence how information is generated, interpreted, and applied in patient care. If used responsibly, it may support safer care. If used without appropriate oversight, it may amplify bias, misinformation, inappropriate recommendations, or unsafe decisions. This is where drug information expertise becomes essential. Preventing future medication harm will require clinical pharmacists to evaluate not only the evidence behind medication therapy, but also the tools and technologies that shape how clinicians and patients understand and apply that evidence.

The Critical Care PRN’s landmark trials database, the Drug Information PRN’s responsible AI work, and the many PRN educational programs shared by PRN leaders all point to a broader truth: preventing harm requires infrastructure. It requires resources, shared knowledge, professional development, and communities willing to do the slow work of translating evidence into practice. This is what makes ACCP the primary home for so many of today’s clinical pharmacists.

Making the Work Visible

Taken together, the examples shared through our PRNs make one thing clear: ACCP members are already writing the next chapter of medication safety. They are doing it through:

• Safer medication decisions
• Clinical pharmacist presence in high-risk settings
• Transitions-of-care work
• Publications, letters, databases, webinars, and educational programming
• Advocacy, technology, pharmacogenomics, stewardship, and patient-centered care

Our challenge now is to make this work more visible. That visibility matters not because we need recognition for its own sake, but because patients, health systems, policymakers, and other health professionals cannot value what they cannot see. Patients may not know that a clinical pharmacist prevented a medication discrepancy at discharge, identified a safer anticoagulation strategy, recognized hypoglycemia risk, questioned a kidney function estimate, or helped ensure that artificial intelligence tools are used responsibly. But those actions can determine whether patients are harmed or protected.

If preventable medication harm is a defining space where clinical pharmacists lead, then we must continue to name that work clearly. We must communicate it in ways patients understand. We must say not only “we optimize therapy,” but also that a clinical pharmacist helps keep you safe. That message is simple. It is also powerful.

A Call for Your Stories

As I continue in this presidential year, I want to keep making clinical pharmacists’ work visible. I encourage ACCP members, PRN committees, and PRN leaders to send me stories, publications, programs, advocacy efforts, patient care models, educational initiatives, or other examples that show how clinical pharmacists are preventing medication harm. The story does not have to be dramatic. In fact, many of the most important stories may be quiet ones: a medication error that was prevented and never reached a patient, an incorrect dosing decision that was corrected, a monitoring plan that prevented toxicity, a discharge process that avoided confusion, or a practice model that made safer care possible.

This “Unwritten” theme is not asking ACCP members to invent a new purpose. It is asking us to reference, connect, and amplify the work already underway.

The examples shared through our PRNs make one thing clear: ACCP members are already writing the next chapter of medication safety. Our task now is to make that work visible, connect it across practice areas, and claim preventable medication harm as a defining space where clinical pharmacists lead.

References

1. Wallace JL, Rungkitwattanakul D, Khan RW, et al. Adopting race-free estimated glomerular filtration rate for unifying medication-related decision-making: an opinion of the Nephrology Practice and Research Network of the American College of Clinical Pharmacy. J Am Coll Clin Pharm.2026;9(2):e70153. https://doi.org/10.1002/jac5.70153
2. Zarowitz BJ, Semla TP, Van C, Dowling TC. Comment on “Adopting race-free estimated glomerular filtration rate for unifying medication-related decision-making: an opinion of the Nephrology Practice and Research Network of the American College of Clinical Pharmacy.” J Am Coll Clin Pharm. 2026;9(2):e70179. https://doi.org/10.1002/jac5.70179
3. Rungkitwattanakul D, St. Peter W, El Nekidy WS, et al.. Reply to comment on “Adopting race-free estimated glomerular filtration rate for unifying medication-related decision-making: an opinion of the Nephrology Practice and Research Network of the American College of Clinical Pharmacy.” J Am Coll Clin Pharm. 2026;9(2):e70180. https://doi.org/10.1002/jac5.70180
4. Gurnani PK, Gayed R, Kane-Gill SL. Comment on “Adopting race-free estimated glomerular filtration rate for unifying medication-related decision-making: an opinion of the Nephrology Practice and Research Network of the American College of Clinical Pharmacy.” J Am Coll Clin Pharm. 2026;9(4):e70200. https://doi.org/10.1002/jac5.70200
5. Carris NW, Evoy KE, Hughes J, Philbrick AM, Singh-Franco D, Lipari M. Comment on “Adopting race-free estimated glomerular filtration rate for unifying medication-related decision-making: an opinion of the Nephrology Practice and Research Network of the American College of Clinical Pharmacy.” J Am Coll Clin Pharm.2026;9(4):e70204. https://doi.org/10.1002/jac5.70204
6. Metzger NL, Adams KK, Khoury A, Kinney EM. Comment on “Adopting race-free estimated glomerular filtration rate for unifying medication-related decision-making: an opinion of the Nephrology Practice and Research Network of the American College of Clinical Pharmacy.” J Am Coll Clin Pharm. 2026;9(4):e70207. https://doi.org/10.1002/jac5.70207
7. Forehand CC, Benken ST, Madorsky M, et al. Pharmacotherapeutic controversies during temperature control after out-of-hospital cardiac arrest: a semi-structured literature review. Pharmacotherapy. 2026;46(1):e70095. https://doi.org/10.1002/phar.70095
8. Abdalla M, Saad M, Abazia D, et al. Responsible use of artificial intelligence in health care: evidence, challenges, and best practices: an opinion of the Drug Information Practice and Research Network of the American College of Clinical Pharmacy. J Am Coll Clin Pharm. 2025;8(12):1333-1361. https://doi.org/10.1002/jac5.70131