Miscommunication between hospitals and community pharmacists at patient discharge can result in incorrect or incomplete medication distribution to patients. This study describes utilization and impact of the Transfers of Care Around Medicines (TCAM) service post-hospital discharge at community pharmacies. An increasing percentage of TCAM referrals were completed post-intervention, but 45% were not completed at all or took longer than one month. The impact of the TCAM service on adverse drug events (ADE) and unintentional medication discrepancies (UMD) was uncertain. Future research may explore reasons for low/late completions or focus on high-risk medications, as those were associated with the most ADE and UMD.

Caregivers and family members offer a unique perspective on patient safety. In this study, patient and caregiver stakeholders outlined the safety threats affecting patients discharged from mental health services and the well-being of caregivers as well as potential solutions. Participants highlighted approaches to improve caregiver involvement, patient and caregiver wellness and education, and the policy and system environments.

Medication safety in inpatient and outpatient settings is a major focus of patient safety efforts. This review included 79 studies on epidemiology, etiology, or interventions related to psychiatric medication safety in primary care (e.g., general practice, community pharmacy, long-term care). Most studies focused on older adults and potentially inappropriate prescribing. The authors recommend future research on wider age groups and underrepresented mental health diagnosis, such as attention deficient hyperactivity disorder (ADHD).

Patients transitioning from the intensive care unit (ICU) to the general ward are vulnerable to medication errors. This qualitative study included medical staff and clinical pharmacists from hospital wards and ICUs to identify factors that contribute to medication safety or adverse events at times of transition. Lack of communication between provider types (e.g., nurse and pharmacist) and time pressure considerations had negative effects on medication safety. Ward rounds and safety culture had positive effects.

Medication errors and adverse drug events (ADE) are unfortunately common at hospital discharge. This study used the National Reporting and Learning System (NRLS) in England and Wales to identify contributing causes to medication errors and ADE. Patients over 65 were the most common age group and, of incidents with a stated level of harm, most did not result in any harm. Overall, most incidents occurred at the prescribing stage, but varied by patient age group. Most contributory factors were organizational (e.g., continuity of care between provider types), followed by staff, patient, and equipment factors.

Clinical decision support (CDS) systems were developed to support safe medication ordering, alerting prescribers to potential unsafe interactions such as drug-drug, drug-allergy, and dosing errors. This study uses a sociotechnical framework to understand the relationship between primary care prescribers’ safety work and CDS. Prescribers described the usefulness of CDS but also noted alert fatigue.

Prisons present unique challenges in providing, as well as in measuring, safe patient care. This article describes structures and processes within prison systems that may contribute to avoidable harm, such as limited staffing and security to travel to healthcare appointments. The result is a two-tier definition taking into consideration the unique context of prison healthcare.

Previous research found that a pharmacist-led information technology intervention (PINCER) reduced dangerous prescribing (i.e., medication monitoring and drug-disease errors) among a subset of primary care practices in the United Kingdom (UK). This longitudinal analysis examined the impact of the PINCER intervention after implementation across a large proportion of general practices in one region in the UK. Researchers found the PINCER intervention decreased dangerous prescribing by 17% and 15% at 6-month and 12-month follow-ups, particularly among dangerous prescribing related to gastrointestinal bleeding.

… with prescription renewals. … Laing L, Salema NE, Jeffries M, et al. Understanding factors that could influence patient …

Patients transferring from the intensive care unit (ICU) to the hospital ward may experience medication errors. This systematic review examined medication-related interventions on the impact of medication errors in ICU patients transferring to the hospital ward. Seventeen studies were included with five identified intervention components. Multi-component studies based on staff education and guidelines were effective at achieving almost four times more deprescribing on inappropriate medications by the time of discharge. Recommendations for improving transfers are included.

Patient safety indicators (PSIs) can be used to identify potential patient safety hazards. Researchers used the Clinical Practice Research Datalink GOLD database to examine prevalence, variation, and patient- and practice-level risk factors for 22 mental health-related PSIs for medication prescribing and monitoring in primary care. The authors found that potentially inappropriate prescribing and inadequate medication monitoring commonly affected patients with mental illness in primary care.

… of those were considered preventable. … Alshehri GH, Ashcroft DM, Nguyen J, et al. Prevalence, nature, severity …

Medication errors are common in mental health hospitals. This study found medication administration and prescribing were the most common stages of medication error. Staff-, organizational-, patient-, and equipment-related factors were identified as contributing to medication safety incidents.

… care, and emergency medicine. … Hodkinson A, Tyler N, Ashcroft DM, et al. Preventable medication harm across …

Patient safety in primary care is an emerging focus for research and policy. The authors of this study retrospectively reviewed case notes from 14,407 primary care patients in the United Kingdom. Their analysis identified three primary types of avoidable harm in primary care – problems with diagnoses, medication-related problems, and delayed referrals. The authors suggest several methods to reduce avoidable harm in primary care, including optimizing existing information technology, enhanced team communication and coordination, and greater continuity of care.

… diseases and type 2 diabetes.   … Williams  R, Jenkins DA, Ashcroft DM, et al. Diagnosis of physical and mental health …

This systematic review of 54 studies found that over half of adult and pediatric patients experienced a medication error post-discharge, and that these errors regularly involved common drug classes such as antibiotics, antidiabetics, analgesics, and cardiovascular drugs. The authors suggest that future research examine the burden of post-discharge medication errors, particularly in pediatric populations.

… the burden of omission errors in psychiatric hospitals. … Keers RN, Hann M, Alshehri GH, et al. Prevalence, nature and predictors of …

The prevalence and nature of medication errors and preventable adverse drug events in pediatric and neonatal intensive care units were examined in this systematic review. In the 35 quantitative studies included in the review, prescribing and medication administration errors were the most common errors reported, with dosing errors the most frequent subtype, in both types of critical care units. The authors concluded that critically ill children admitted to intensive care units frequently experience medication errors and identified important targets to guide remediation efforts.

Most patient safety research has focused on tertiary care or specialty care settings, but less is known about safety in primary care settings and there is no clear definition of patient safety incidents and harm occurring in these settings.  The authors convened a panel of family physicians and used a consensus method to define “avoidable harm” within family practice. Most scenarios found to be avoidable and included in the proposed definition involved failure to adhere to evidence-based practice guidelines, lack of timely intervention, or failure in administrative processes, such as referrals or procedures for following up on results.