Implementing a Successful Medication Verification Process in the ED: Lessons Learned from a Level I Trauma Center Serving a Rural Population

Background: Emergency department (ED) adoption of required prospective pharmacist review of medication orders can often be limited due to staffing and care delay concerns. Yet, prospective pharmacist review is known to mitigate prescribing errors and improve patient safety. This study evaluated the impact of an expanded implementation of prospective medication review (PMR) in a metropolitan emergency department (ED) of a Level I Trauma center that serves a large geographic area including rural tracts. Methods: This study performed a secondary analysis of a prospective, single-center, observational pre-/post- implementation study (Dec 2023–Feb 2025) evaluating expanded required prospective verification for non-urgent medications stocked in ED automated dispensing cabinets (ADCs). This sub-analysis quantified change in process-time variability from pre- to post-implementation, excluding orders dispensed via ADC override. The primary outcome was time (minutes) for medication-use process intervals, with an emphasis on order-entry-to-verification dispersion. Results: Amongst the 2,379 orders not dispensed via override (pre n=1,405; post n=974), there was slight decrease in mean order-entry-to-verification (5.93 to 5.69 minutes; p= 0.425), and variability significantly decreased (standard deviation 7.68 to 6.12 minutes; p= 0.002). No significant differences were observed in means or variances ( p-values >0.05) for the process intervals for order entry to verification or dispense to administration. The total order-entry-to-administration time was not delayed (37.1 to 39.7 minutes; p =0.115) indicating an efficient and effective process post-implementation. Conclusion: Expanded prospective verification did not delay medication verification, dispense or administration and was associated with a more predictable verification process, supporting feasibility in other Level I trauma EDs serving a geographically dispersed population. Application: PMR implementation was enabled through shared mental models and cross-disciplinary workflow alignment, coupled with staffing model adjustments, and workflow reconfiguration.