When Systems Fail: Pharmacy Leaders Call for Change, Not Criminal Charges

BETHESDA, MD – August 21, 2026 – In a rare joint statement, two of the nation’s most influential pharmacy organizations today addressed the tragic, reported harm of patient Glenda Dorton and others, pivoting from expressions of sympathy to a forceful call for a fundamental shift in how the healthcare industry responds to medical errors. The American Society of Health-System Pharmacists (ASHP) and the American Pharmacists Association (APhA) are advocating for a systemic overhaul, urging a move away from a culture of individual blame and toward a model known as a 'just culture.'

Their statement, prompted by a devastating medication error, underscores a deep-seated tension within modern medicine: when a patient is harmed, who is truly at fault? The individual who made the mistake, or the complex, often fragile system they operate within? For these leading pharmacy groups, representing tens of thousands of professionals, the answer is clear. They “stand firmly against punitive actions that criminalize medication errors,” arguing that sustainable safety comes from dissecting and reinforcing “underlying system vulnerabilities.” This position transforms a moment of tragedy into a critical inflection point for patient safety, professional accountability, and the very culture of healthcare itself.

The Anatomy of an Error: Beyond a Single Mistake

While the specifics of the incident involving Glenda Dorton remain private, the event serves as a poignant reminder of a pervasive issue. Medication errors are not rare anomalies; they are a grim feature of the healthcare landscape, harming an estimated 1.3 million Americans annually. These events are rarely the result of a single, malicious act. Instead, they are often the catastrophic culmination of multiple, smaller failures in process, technology, and communication—what safety science pioneer James Reason famously termed the “Swiss Cheese Model” of accident causation, where holes in multiple layers of defense line up to allow a hazard to pass through.

This is the philosophy underpinning the 'just culture' model, a concept developed by experts like Reason and David Marx for high-risk industries. It provides a framework for moving beyond the knee-jerk reaction of blaming an individual. A 'just culture' differentiates between three types of behavior. First is simple human error—an inadvertent slip or lapse, which is seen as an inevitable part of the human condition and an opportunity for learning. Second is at-risk behavior, where a professional makes a choice that increases risk, often because they mistakenly believe it is justified or have seen it normalized by workplace culture. Finally, there is reckless behavior, a conscious and unjustifiable disregard for safety protocols.

Proponents argue that only reckless behavior warrants punitive action. In contrast, human error and at-risk behavior should trigger supportive coaching and, most importantly, a deep dive into why the system allowed or even encouraged that error to occur. “When you punish human error, you’re not creating safety; you’re creating silence,” a patient safety analyst explained. “And silence is the enemy of improvement. It drives mistakes underground, guaranteeing they will happen again.”

A Chilling Effect: The Debate Over Criminalization

The call from ASHP and APhA to reject the criminalization of errors is not happening in a vacuum. It echoes a fierce, ongoing debate that intensified following the high-profile criminal conviction of former nurse RaDonda Vaught in 2022 for a fatal medication error. That case sent what many called “shockwaves” through the nursing and medical communities, sparking fears that any mistake, no matter how unintentional, could lead to prison time.

Professional organizations argue that this precedent has a dangerous chilling effect on error reporting. If healthcare workers fear criminal prosecution for reporting a mistake or a near-miss, they are far less likely to do so. This robs organizations of the critical data needed to identify patterns, fix broken workflows, and prevent future harm. The focus shifts from collective learning to individual self-preservation, a dynamic that ultimately puts more patients at risk.

“No pharmacist, physician, nurse, technician, or other healthcare professional comes to work intending to harm a patient,” the joint statement reads. This assertion is central to the argument against criminalization. The legal system is designed to adjudicate intent, but the vast majority of medical errors are born from flawed processes, staff fatigue, confusing drug labels, or inadequate technological safeguards—not malice. A 'just culture' seeks accountability through professional licensing boards and internal quality improvement, reserving the blunt instrument of criminal law for the rarest cases of willful harm.

The Pharmacist’s Frontline Role in a Complex System

Often unseen by the public, pharmacists are central figures in the architecture of medication safety. Their role extends far beyond dispensing medications from behind a counter. In modern health systems, clinical pharmacists are deeply integrated into patient care teams, serving as the final, critical checkpoint in the complex medication-use process.

These professionals are responsible for designing and maintaining the very safeguards meant to prevent errors. This includes everything from implementing barcode scanning systems that verify a drug at a patient’s bedside to developing protocols for high-alert medications that carry an elevated risk of harm. They perform medication reconciliation during hospital admissions and discharges to prevent dangerous omissions or duplications and work with IT departments to optimize electronic health records to provide clearer warnings about drug interactions or allergies.

The rise of automation and artificial intelligence is further augmenting this role. AI-powered systems can now scan millions of prescriptions to flag potential errors, identify unusual dosing patterns, and reduce mix-ups between look-alike/sound-alike drugs. However, experts are clear that these technologies are tools to support, not replace, the pharmacist’s clinical judgment. It is the pharmacist who must interpret the AI’s alert, understand the patient’s unique context, and make the final safety determination.

The Second Victim: The Hidden Toll of Medical Errors

Lost in the conversation about patient harm and accountability is often the profound and lasting trauma experienced by the healthcare professional involved in the error. Coined by Dr. Albert Wu, the term 'second victim' describes the clinician who must live with the emotional devastation of having been a part of an adverse patient event.

These professionals often experience intense feelings of guilt, anxiety, depression, and a loss of confidence that can lead to burnout or even cause them to leave their profession entirely. A punitive culture exacerbates this trauma, isolating the individual and offering no path toward healing or constructive resolution. In contrast, a 'just culture' recognizes the 'second victim' experience and mandates organizational support, such as peer counseling and structured debriefings after an event.

Supporting these clinicians is not about deflecting responsibility; it is a core component of a healthy safety culture. When healthcare workers feel supported and know that an honest mistake will be treated as a learning opportunity, they are more likely to remain engaged, transparent, and committed to improving the very systems that failed them and their patient. As the joint statement implies, honoring those harmed by medication errors requires a dual commitment: one to the patients who suffer and one to creating a system that supports the fallible, dedicated humans working within it.