This week I was thinking about the director of pharmacy at my last hospital. I used to run into her when she surfaced periodically for meetings; she was always rushing, always carrying a big sheaf of papers, and always doing paperwork whenever she was out of the pharmacy. What I remember most is the stunned look she always had. Our hospital had a great record on medication reconciliation—so good in fact that JCAHO told us we could be an example for other hospitals. But the pharmacist….I can’t get her out of my mind. She told me once she routinely worked twelve hour days, weekends—there was such a staffing shortage that I think a pharmacist position had been posted for something like two years. It looked like the most stressful job in the hospital. Reconciliation, alerts, root cause, so much of that tied back to pharmacy. What went on down there? I’m starting to write about the pharmacy segment of closed loop med admin. And I want to be sure I tell the real story. If you want to talk about what goes on in your place, either the nightmares or the happy ending, email me. I’d call my old pharmacy director, but I know I’d never get through.