Why Every ICU Patients Needs a Critical Care Pharmacist Specialist

By  Nadia H.Ismail,MSc, BPharm, FCCM

Every ICU ought to have a critical care pharmacist dedicated to the team, since their involvement is associated with fewer deaths, shorter ICU stays, and substantially fewer medication errors and adverse drug events.

The intensive care unit ranks among the most medication-heavy areas of a hospital. Patients are given many drugs simultaneously, often as continuous infusions, while their kidneys, liver, and circulation change from one hour to the next. In such a setting, a minor dosing mistake can rapidly escalate into serious harm. Three decades of research from early 1990s reports through to reviews published in 2026 all point to the same conclusion: place a trained critical care pharmacist at the bedside.

What critical care pharmacists do for critically ill patients?

A critical care pharmacist is a specialist who takes charge of the medication aspects of ICU care, collaborating with physicians, nurses, and other clinicians at the bedside rather than working from a distant dispensary. Over several decades the role evolved from a dispensing function into an essential member of the bedside team (Horn & Jacobi 2006; Papadopoulos et al. 2002).

Critical care pharmacist activities

• Takes part in rounds with the team. They take part in daily multidisciplinary rounds and review each patient's medication list in real time (Lat et al. 2020; MacLaren & Devlin 2019).

• Adapts drugs and doses. They modify doses for kidney and liver failure, shock, obesity, dialysis, and other organ support, situations in which standard doses often fall short (Sikora 2023).

• Detects problems before they reach the patient. They identify incorrect doses, drug interactions, duplications, omissions, and allergies at the prescribing stage (Bourne et al. 2018; Rudall et al. 2017).

• Drives proactive improvements. Many of their interventions are not corrections of errors but optimizations, for instance switching to a better agent or discontinuing a drug that is no longer needed (Bourne et al. 2014).

• Oversees high-risk therapies. Sedation, analgesia and delirium, antimicrobials, anticoagulation, vasopressors, nutrition, and therapeutic drug monitoring all fall within their remit (Lat et al. 2020; Holden et al. 2026).

• Responds to emergencies. They take part in resuscitations and assist in preparing and dosing emergency medications swiftly and safely (Lat et al. 2020).

• Seamless transitions. They review and reconcile medications when patients are admitted to and transferred from the ICU, ensuring that needed drugs are restarted and ICU-specific drugs are discontinued (Lat et al. 2020).

What does a critical care pharmacist do for the health care team and the hospital?

• Immediate drug information. They respond to bedside questions, ranging from IV compatibility to dosing in uncommon situations (Montazeri & Cook 1994).

• Teaching. They provide education to physicians, nurses, residents and pharmacy trainees (Lat et al. 2020; LeBlanc et al. 2008).

• Protocols and policy. They develop ICU order sets and guidelines and serve on pharmacy and therapeutics committees (Ismail et al. 2023).

• Stewardship and cost control. They spearhead antimicrobial stewardship and cost-conscious prescribing (Crosby et al. 2023).

• Research and quality. They carry out quality-improvement projects and research on medication safety (Heavner 2024; Sikora 2023).

The Society of Critical Care Medicine and the American College of Clinical Pharmacy categories these duties into essential, desirable and optimal tiers spanning patient care, quality, education, research and administration (Lat et al. 2020). As Dasta and Jacob noted back in 1994, what these pharmacists contribute goes well beyond what is visible on rounds.

Why we need critical care pharmacists?

We need critical care pharmacists because ICU drug therapy is too complex and too unforgiving to manage without a dedicated expert, and professional bodies now describe the role as essential.

ICU patients face a uniquely high risk of medication harm. They receive more medications than other inpatients, many of them high-alert infusions, while shifting organ function changes how each drug behaves. As a result errors and adverse drug events occur more often and pose greater danger in this population (Bourne et al. 2018; Wang et al. 2015).

Pharmacists uncover problems that no one else is checking for. Multicentre research in the UK demonstrated that critical care pharmacists intervene on a substantial proportion of the prescriptions they review, and that many of these interventions avert harm or improve therapy (Rudall et al. 2017; Bourne et al. 2014). These same studies showed that experience and specialist training increase the clinical impact of such interventions, meaning a dedicated, trained ICU pharmacist is more valuable than occasional coverage.

The standards require it. The SCCM/ACCP position paper identifies bedside participation in rounds and medication review as essential rather than optional (Lat et al. 2020). Some editorialists have taken this further, describing the bedside critical care pharmacist as a mandatory member of the ICU team (MacLaren & Devlin 2019).

Coverage nevertheless remains inconsistent. Workforce surveys in the UK revealed that pharmacist staffing in many ICUs continues to fall below national recommendations (Borthwick et al. 2023). Pharmacists in the US report heavy patient loads and are calling for clearer, safer practice models and staffing ratios (Smith et al. 2024; Sikora 2023). Night shifts are an especially notable gap: a single US hospital found only 6.2% compliance with core patient-care recommendations during overnight hours before it added a night-shift ICU pharmacist (Oh et al. 2026).

Any new position has to be justified in business terms. Hospital leaders typically fund roles on the basis of cost and quality data, so part of securing each new post involves translating bedside value into outcomes that executives recognize (Rech & Gomez 2022; Forehand et al. 2023; Heavner 2024).

How their presence affects patient outcomes

The strongest evidence indicates that adding a critical care pharmacist to the ICU team is linked to roughly 22% lower odds of death, a shorter ICU stay, and about three-quarters fewer preventable adverse drug events.

 Summary of studies on Impact of ICU Pharmacist on Patient outcomes

Outcome	Effect with a critical care pharmacist	Source
Mortality	Odds ratio 0.78 (95% CI 0.73–0.83)	Lee et al. 2019
ICU length of stay (mixed ICUs)	1.33 days shorter (95% CI 0.90–1.75)	Lee et al. 2019
Preventable adverse drug events	Odds ratio 0.26 (95% CI 0.15–0.44)	Lee et al. 2019
Non-preventable adverse drug events	Odds ratio 0.47 (95% CI 0.28–0.77)	Lee et al. 2019
Prescribing errors and preventable ADEs	Significantly reduced	Wang et al. 2015
Overall medication errors	No significant reduction across pooled studies	Wang et al. 2015

Safety of medications. The most obvious benefit of the pharmacist's role is the reduction of prescribing errors and the harm associated with them. Wang and colleagues found significant decreases in prescribing errors and preventable adverse drug events, despite not seeing reductions overall for medication errors. They called for more rigorous study, a caveat that is worth remembering in any advocacy effort (Wang et al. 2015).

Mortality and duration of stay. A combination of randomized and non-randomised studies by Lee and colleagues found lower mortality and shorter ICU stays when a pharmacist was part of the team (Lee et al. 2019). The accompanying editorial argued that these findings make the bedside pharmacist indispensable (MacLaren & Devlin 2019).

Wider clinical outcomes. A 2026 scoping review found that particular pharmacist activities, such as antimicrobial stewardship, sedation management and anticoagulation, were linked to clinically important outcomes and recommended future research that evaluated patient-level outcomes rather than counting interventions (Holden et al. 2026; Heavner 2024).

Care available at all hours. Introduction of an overnight ICU pharmacist at one hospital led to increased adherence to core patient-care recommendations from 6.2% to 67.2%. Recorded interventions increased without delay to order verification or drug administration (Oh et al. 2026).

Expense. Economic evaluations of adult ICU pharmacy services typically find cost savings or cost avoided outweighing the cost of the pharmacist, despite methodological differences across studies (Crosby et al. 2023). Earlier studies in the 1990s also found interventions that improved care while reducing drug costs (Montazeri & Cook 1994).

The situation in Saudi Arabia and across the globe

Critical care pharmacy is established in Saudi Arabia, but the next step is to ensure it is available to everyone, at all hours. Services began in the early 2000s driven by pharmacists with US and UK Pharmacy degrees and residency training. A national survey found that 78.2% of Saudi critical care pharmacists serve on pharmacy and therapeutics committees and 56.5% on critical care committees (Ismail et al. 2023).

Globally, the scope of ICU pharmacist practice varies greatly between countries and hospitals (LeBlanc et al. 2008; Borthwick et al. 2023). This variability means that many ICU patients do not have a specialist reviewing their medications each day.

The key takeaways

Having a critical care pharmacist in every ICU is not a luxury - it is a safety requirement, supported by more than 30 years of evidence. To achieve this goal, hospitals should:

1. Fund at least one dedicated, specialty-trained pharmacist per ICU who participates on rounds each day.

2. Establish safe pharmacist-to-patient ratios and extend coverage to nights and weekends.

3. Monitor patient-level outcomes, such as adverse drug events, length of stay and mortality, to ensure and demonstrate the value of these positions.

4. Invest in residency and fellowship training programs to expand critical care pharmacist workforce.

References

1.       Borthwick M, Barton G, Ioannides CP, et al. Critical care pharmacy workforce: a 2020 re-evaluation of the UK deployment and characteristics. Hum Resour Health. 2023;21(1):28. doi:10.1186/s12960-023-00810-y

2.       Bourne RS, Choo CL, Dorward BJ. Proactive clinical pharmacist interventions in critical care: effect of unit speciality and other factors. Int J Pharm Pract. 2014;22(2):146-54. doi:10.1111/ijpp.12046

3.       Bourne RS, Shulman R, Jennings JK. Reducing medication errors in critical care patients: pharmacist key resources and relationship with medicines optimisation. Int J Pharm Pract. 2018;26(6):534-540. doi:10.1111/ijpp.12430

4.       Crosby A, Jennings JK, Mills AT, Silcock J, Bourne RS. Economic evaluations of adult critical care pharmacy services: a scoping review. Int J Pharm Pract. 2023;31(6):574-584. doi:10.1093/ijpp/riad049

5.       Dasta JF, Jacob J. The critical care pharmacist: what you get is more than what you see. Crit Care Med. 1994;22(6):906-9.

6.       Forehand C, Keats K, Amerine LB, Sikora A. Rethinking justifications for critical care pharmacist positions: translating bedside evidence to the C-suite. Am J Health Syst Pharm. 2023;80(18):1275-1279. doi:10.1093/ajhp/zxad122

7.       Heavner MS. Next generation of critical care pharmacist practice studies: beyond essential. Am J Health Syst Pharm. 2024;81(18):884-889. doi:10.1093/ajhp/zxae146

8.       Holden DN, Groth CM, Acquisto NM, et al. Measuring critical care pharmacist value: a scoping review of the effect of critical care pharmacist activities on clinically relevant outcomes. J Am Coll Clin Pharm. 2026;9(3):e70188. doi:10.1002/jac5.70188

9.       Horn E, Jacobi J. The critical care clinical pharmacist: evolution of an essential team member. Crit Care Med. 2006;34(3 Suppl):S46-51. doi:10.1097/01.CCM.0000199990.68341.33

10.   Ismail NH, Alhammad AM, Alshaya AI, Alkhani N, Alenazi AO, Aljuhani O. Characteristics of critical care pharmacy services in Saudi Arabia. J Multidiscip Healthc. 2023;16:3227-3234. doi:10.2147/JMDH.S434116

11.   Lat I, Paciullo C, Daley MJ, et al. Position paper on critical care pharmacy services (executive summary): 2020 update. Crit Care Med. 2020;48(9):1375-1382. doi:10.1097/CCM.0000000000004438

12.   LeBlanc JM, Seoane-Vazquez EC, Arbo TC, Dasta JF. International critical care hospital pharmacist activities. Intensive Care Med. 2008;34(3):538-42. doi:10.1007/s00134-007-0918-2

13.   Lee H, Ryu K, Sohn Y, Kim J, Suh GY, Kim E. Impact on patient outcomes of pharmacist participation in multidisciplinary critical care teams: a systematic review and meta-analysis. Crit Care Med. 2019;47(9):1243-1250. doi:10.1097/CCM.0000000000003830

14.   MacLaren R, Devlin JW. The bedside critical care pharmacist: a mandatory ICU team member essential for patient care. Crit Care Med. 2019;47(9):1276-1278. doi:10.1097/CCM.0000000000003888

15.   Montazeri M, Cook DJ. Impact of a clinical pharmacist in a multidisciplinary intensive care unit. Crit Care Med. 1994;22(6):1044-8. doi:10.1097/00003246-199406000-00027

16.   Oh Y, Ackerbauer KA, Kong S, Nicholson EM, Feeney ME. Implementation and evaluation of an overnight critical care pharmacist shift. Am J Health Syst Pharm. 2026;83(Suppl 1):S33-S40. doi:10.1093/ajhp/zxaf341

17.   Papadopoulos J, Rebuck JA, Lober C, et al. The critical care pharmacist: an essential intensive care practitioner. Pharmacotherapy. 2002;22(11):1484-8. doi:10.1592/phco.22.16.1484.33694

18.   Rech MA, Gomez TA. What generates critical care pharmacist positions in the "real world"? Am J Health Syst Pharm. 2022;79(18):1513-1514. doi:10.1093/ajhp/zxac170

19.   Rudall N, McKenzie C, Landa J, Bourne RS, Bates I, Shulman R. PROTECTED-UK: clinical pharmacist interventions in the UK critical care unit. Int J Pharm Pract. 2017;25(4):311-319. doi:10.1111/ijpp.12304

20.   Sikora A. Critical care pharmacists: a focus on horizons. Crit Care Clin. 2023;39(3):503-527. doi:10.1016/j.ccc.2023.01.006

21.   Smith ZR, Palm NM, Smith SE, et al. Critical care pharmacist perspectives on optimal practice models and prioritization of professional activities: a cross-sectional survey. Am J Health Syst Pharm. 2024;81(24):1267-1277. doi:10.1093/ajhp/zxae151

22.   Wang T, Benedict N, Olsen KM, et al. Effect of critical care pharmacist's intervention on medication errors: a systematic review and meta-analysis of observational studies. J Crit Care. 2015;30(5):1101-6. doi:10.1016/j.jcrc.2015.06.018

Critical Care Pharmacy Practice in Saudi Arabia

By  Nadia H.Ismail,MSc, BPharm,FCCM

Why this review

Saudi critical care pharmacy has evolved from a handful of US and UK, trained pioneers in the 1980s–2000s to a recognized specialty with board-certified practitioners, a national network of critical care pharmacists, residency programs, and a burgeoning research enterprise. This post aims to provide an integrated summary of this literature for Pharmacy directors, pharmacy residents, and hospital managers to build , enhance and improve critical care pharmacy services in their institution.

Scope

Peer-reviewed manuscripts with a Saudi setting and authorship that focus on critical care pharmacy practice, training and their impact on patient care, or on ICU therapy research led by Saudi critical care pharmacists. The papers are grouped by theme, not chronologically.

A word on scope

Any review aiming to be comprehensive is necessarily limited by the availability of published literature. The ICU pharmacy specialty in Saudi Arabia has seen more than a hundred manuscripts published by local authors since 2020, including large multinational cohort studies. This post provides an overview of landmark and representative studies in each theme, all of which have been evaluated according to their abstracts. Your suggestions of additional relevant manuscripts are welcome for future updates.

i. Workforce, Services, and Training

The practice-related literature reveals an uneven development of ICU pharmacy services across the country: while most regional hospitals still lack critical care pharmacists, they are present in most large tertiary medical centers. Out of the 130 hospitals with ICUs to which surveys were sent, 94 (72%) responded. Forty-three percent of responding hospitals had an ICU multidisciplinary team structure that included a pharmacist who visited the unit during medical rounds. Up to 54% of the hospitals with CCP services had one dedicated pharmacist present at bedside and during medical rounds. Approximately 78% of the ICU pharmacists performed one or more clinical activities. Training pharmacy interns was one of the major educational activities provided by ICU pharmacists. Clinical services (42%) were the most needed services, followed by educational (14%) activities. Limited job availability was the main barriers to having CCP services among hospitals (April 2020).

Critical care pharmacy practice in Saudi Arabia: a review by SSCP Critical Care and Emergency Medicine PSN) board members of 2020. A narrative literature review combined with qualitative interviews with local pioneers’ sheds light on the specialty’s early development and emerging challenges.  The review describes critical care pharmacy services in Saudi Arabia by analyzing their historical development across patient care See Fig.1, education, scholarly research, and professional leadership, while outlining current challenges and strategic opportunities for professional advancement (Aug 2021)

Fig.1

Key Findings

• Historical Growth & Scholarship Impact: Clinical services began in the late 1970s and 1980s through centralized satellite pharmacies and Drug-Poison Information Centers. Strategic government scholarship initiatives—notably the King Abdullah Scholarship Program—enabled approximately 500 Saudi pharmacists to earn Pharm.D. degrees, with over 350 completing postgraduate residency or fellowship training in North America.

• Regional Credentialing Leadership: Board Certified Critical Care Pharmacist (BCCCP) holders in Saudi Arabia grew from 18 in 2018 to 48 in 2021, making it the leading country in the Middle East for credentialed critical care specialists.

• Workforce Deficit & Patient Ratios: Although total intensive care unit (ICU) capacity expanded to 10,950 beds by 2020, a severe workforce shortage persists: there are roughly 49 board-certified critical care pharmacists serving 10,950 ICU beds (an average ratio of 1 pharmacist per 224 beds). In major tertiary hospitals, individual practitioners frequently care for 15 to 30 patients.

• Geographic & Operational Constraints: Specialized pharmacists and PGY-2 critical care residency training programs are heavily concentrated in major urban centers such as Riyadh. Furthermore, clinical coverage is largely restricted to 8-hour day shifts on weekdays, with minimal off-hour or weekend service.

• Research Contributions & Institutional Leadership: Saudi critical care pharmacists actively participate in major randomized clinical trials (such as MIRACLE and ATTAINMENT) through initiatives like the Saudi Critical Care Trials Group (SCCTG). In 2020, the Saudi Society of Clinical Pharmacy (SSCP) launched the Critical Care and Emergency Medicine Specialty Network to formalize national standards. However, research output remains limited by sparse funding, a lack of senior research mentors, and language barriers.