Researchers identified two needs of the in-hospital pediatric retail pharmacy. First was the reduction of the risk and frequency of errors. Second was the need to improve the efficiency of primary pharmacy tasks. Interruptions were identified as the primary issue. The team performed an extensive literature review and conducted interviews and observations to assess the pharmacy work system, work How, and the impact of interruptions. A human factors analysis was done to accurately represent the pharmacy work system from data collection, and derive recommendations to improve efficiency and accuracy. Some of the recommendations were rapidly implemented into the pharmacy work system, including increased staffing during periods of high work demand, changes to counter spacing, and design changes to bags intended to contain refrigerated components. The research team conducted follow-up observations and collected survey data from pharmacy staff to determine the impact of the implemented interventions and identify key improvements.