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PSNet: Patient Safety Network

Investigation into the Role of Clinical Pharmacy Services in Helping to Identify and Reduce High-risk Prescribing Errors in Hospital.

Farnborough, UK: Healthcare Safety Investigation Branch; September 24, 2020. 

Unit-based pharmacy services help to mitigate and catch medication errors. This report highlights a case of a medication error death and describes how embedding clinical pharmacy services could have prevented this incident. The report provides system level recommendations to enhance this service including defining the role of clinical pharmacy teams and prioritizing the tactic as an important improvement strategy.