Newswise — LOS ANGELES (Oct. 27, 2025) — A new state bill containing an important patient safety amendment aimed at reducing medication errors becomes California law at the stroke of midnight on Jan. 1, thanks largely to the advocacy efforts of Cedars-Sinai’s pharmacy leader.
“This is a major breakthrough for patient safety in California,” said Rita Shane, PharmD, Cedars-Sinai vice president and chief pharmacy officer. Shane helped craft the new law’s language regarding medication reviews when high-risk patients are discharged from a hospital.
Shane said it is essential to review the discharge medication list to make sure that the medications patients take home are correct since the medications they were on prior to hospitalization may need to be changed or discontinued if new treatments have been added.
The new law closes a gap in patient safety and will lead to pharmacist-led medication reviews for high-risk hospital patients when they are discharged. Studies of the medication review practice at discharge—already implemented at Cedars-Sinai for years—demonstrate dramatically lower errors, by as much as 60%.
A Personal Experience With Medication Error
The issue of patient safety has always been a priority for Shane, but it became personal in 1998 when her father was admitted to a hospital for cancer that had metastasized to his brain.
As his condition worsened, Shane’s father was transferred from one hospital to another. In this transition of care, the new hospital did not review his medication list, leading to the abrupt discontinuation of a medication, which triggered an extreme side effect.
“I saw firsthand the negative impact medication reconciliation errors could have on patient care,” Shane said. “From then on, I made it my mission to prevent this from happening to other families.”
Advocacy in Action
In 2018, 20 years after her father’s passing, Shane helped draft and pass a state bill that requires pharmacy staff to review medication profiles for high-risk patients upon admission at acute-care hospitals with more than 100 beds.
The new legislation focusing on medication reviews when patients are discharged serves as a bookend to her original advocacy work.
When combined, the two laws are expected to better protect patients and minimize the risk of medication errors, which present a growing risk due to what Shane calls the “poly problem.” The term refers to the increasing number of patients who have multiple chronic diseases and who often need treatment by multiple physicians and are prescribed multiple drug therapies.
“These errors are not intentional,” Shane said. “But there are so many moving parts, the errors can, unfortunately, be introduced, which threatens patient safety and can lead to what should be avoidable hospital readmissions.”
Shane said she is already receiving inquiries about the legislation from hospital pharmacists at healthcare centers outside California who want similar measures adopted in their home states. She hopes to someday see these policies enacted nationwide.
Read more from Cedars-Sinai Magazine: How to Manage Multiple Prescriptions
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