Although best practices that support safe and reliable medication therapy exist, they are not uniformly embedded in care delivery. This three-part series discusses medication safety risks and highlights topics such as wrong-patient orders, inadequate patient understanding of drug instructions, and poor lighting.

Examining how safety culture influences behavior, this commentary describes a study that identified factors likely to affect clinician adoption of peers' professional or safety-related behaviors, including beliefs in the system approach, error disclosure, and risk reduction strategies.

… and factors that contribute to attentiveness. … Grissinger M. 'Inattentional blindness': what captures your …

This commentary discusses standards related to workspace design that can help address interruptions, noise, and other distractions to prevent medication errors.

Patient safety reporting systems are commonplace in most organizations as a tool to identify, track, and potentially prevent adverse events despite their known limitations. Heparin is a high-risk medication that frequently generates incident reports, and significant efforts have been established to ensure its safe use. This study reviewed reported heparin errors from three large patient safety reporting systems—MEDMARX, the Pennsylvania Patient Safety Authority, and the University Health Consortium (an alliance of academic medical centers)—to capture events from more than 1000 organizations. Of the 300,000 medication events reported, approximately 4% involved heparin products, with the administration phase being the most frequently cited. As this was the first study to combine three large sources of reporting data for a single process, the authors point out the consistent patterns detected, suggesting diminishing returns from aggregating reports around common events.

Based on reports received through numerous national organizations, this article provides public policy recommendations for preventing certain tubing misconnections.