Judy Smetzer, BSN, FISMP, is Vice President at the Institute for Safe Medication Practices (ISMP). In 1998 she completed a one-year fellowship with ISMP, which provided training in adverse drug event management and prevention. Currently, Smetzer is one of the authors and editors of five ISMP newsletters—for hospitals, nurses, community pharmacies, long-term care facilities, and consumers. These publications reach more than 1.5 million readers. She is a certified trainer in Just Culture, co-teaches a Medication-Safety Focused Just Culture Champion Certification Course with Outcome Engenuity, and has presented to varied healthcare audiences on this topic and many others related to human factors and medication safety. The American Public Health Association honored Smetzer with the 2002 Avedis Donabedian Award for her work in medication safety. In 2012, Smetzer was awarded The Way-Paver for BPOC (Bar-code Point of Care) Award from the TerraPharma Project. She is also the 2013 recipient of the American Society of Health-System Pharmacists (ASHP) Board of Directors’ Award of Honor.