Nashville, TN (August 20, 2026) – The Tennessee Pharmacists Association (TPA) recognizes the concern generated by reports of a significant medication error within a Tennessee healthcare setting. While the circumstances surrounding any individual event must be thoroughly reviewed by the organizations involved, TPA believes incidents such as these underscore the importance of maintaining a healthcare environment grounded in patient safety, transparency, accountability, and continuous learning.
TPA strongly supports the Just Culture approach to medication safety and will continue to encourage the implementation of Just Culture principles in health systems, pharmacies, and other healthcare institutions throughout Tennessee. Just Culture recognizes that while healthcare professionals are accountable for their actions, medication errors can result from a combination of human factors, system vulnerabilities, workflow design, communication challenges, and other organizational influences. A Just Culture framework promotes the identification and correction of these underlying issues to prevent future harm.
“As pharmacists, patient safety is our highest priority,” said TPA President Brent Dunlap. “When a serious medication errors, or even when a near miss is identified, our focus should be on understanding what happened, learning from the event, and strengthening systems to reduce the likelihood of recurrence. A culture that encourages reporting, transparency, and continuous improvement ultimately leads to safer care for patients.”
TPA also reaffirms its longstanding recommendation that pharmacies and healthcare organizations adopt and maintain Continuous Quality Improvement (CQI) programs, such as the Pharmacy Quality Commitment+ (PQC+) offered by the Alliance for Patient Medication Safety. Effective CQI programs provide structured processes for identifying medication-use risks, analyzing errors and near misses, implementing corrective actions, and evaluating outcomes. Through ongoing monitoring, evaluation, and improvement, organizations can reduce patient harm and enhance medication safety across all care settings.
TPA supports the efforts of pharmacists, pharmacy technicians, nurses, physicians, and other healthcare professionals who work diligently every day to implement Just Culture principles and quality improvement initiatives within their respective practices and institutions. Healthcare professionals must be empowered to report concerns, identify system weaknesses, and participate in meaningful safety improvements without fear that honest mistakes will lead automatically to punitive responses.
The Association encourages healthcare leaders throughout Tennessee to use medication safety events as opportunities for learning and system enhancement. By investing in Just Culture practices, robust CQI programs, staff education, and interdisciplinary collaboration, healthcare organizations can strengthen patient safety and support the professionals entrusted with patient care.
TPA remains committed to advancing policies, education, and best practices that improve medication safety and foster a culture of continuous quality improvement across Tennessee.
About the Tennessee Pharmacists Association
The Tennessee Pharmacists Association represents the profession of pharmacy across the state, united for the purpose of promoting safe and effective medication use to improve the health of patients. Since 1886, the Tennessee Pharmacists Association has preserved and advanced the interests of the profession and has served the professional needs of all pharmacists, student pharmacists, and pharmacy technicians. For more information, please visit tnpharm.org.