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.

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.

… related to gastrointestinal bleeding. … Rodgers S,  Taylor AC, Roberts SA, et al. Scaling-up a pharmacist-led …

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 health …

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 …

… 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.

The extent of harm due to patient safety problems varies across studies. This systematic review sought to estimate the prevalence of preventable harm in medical care overall. Researchers synthesized data from 70 studies and estimated that 6% of patients receiving medical care experience preventable harm. Harm related to medications, diagnosis, health care–associated infections, and procedures accounted for significant proportions of preventable harm. The authors conclude that focusing on evidenced-based strategies to address preventable patient harm would improve health care quality and subsequently reduce costs. A related editorial calls for improving measurement of preventable harm. Another editorial spotlights the importance of understanding the causes of preventable harm in health care.

This qualitative study evaluated a pharmacist technician–supported intervention to prevent errors of omission in medication administration. Most participants reported positive impacts of the intervention, but some pharmacy technicians failed to consistently observe nurses, citing feeling their presence was intrusive. Not all participants perceived the intervention as effective, leading to deviation from intended protocol. These findings highlight the challenge of implementing interventions across health care roles.

This study convened focus groups that included the public, patients, and caregivers to define a framework for medication safety problems. Participants described the importance of factors such as communication, supply of medications, health information technology, access to care, and continuity with physicians. The authors suggest that this framework clarifies patient perspectives on medication safety.

Using clinical vignettes, investigators conducted semi-structured interviews with those prescribing medications in a pediatric intensive care unit to better understand human factors contributing to prescribing errors. They found that cognitive load was the main contributor to such errors.

In this qualitative study, researchers followed the progress of the improvement work taken on by 10 English community pharmacies that participated in improvement workshops over a 1-year period. Using a behavioral change framework, they were able to describe the pharmacies' progress in their activities as well as identify particular organizational factors facilitating improvement work.

This interview study used a human factors method, the critical incident technique, to identify underlying factors in medication administration errors in a mental health inpatient facility. The team identified multiple interconnected vulnerabilities, including inadequate staffing, interruptions, and communication challenges. The findings underscore the persistence of widely documented medication safety administration concerns.

Pharmacists enhance medication safety in hospitals and ambulatory settings. The authors interviewed pharmacists about their experience implementing a dashboard that allowed them to identify and provide feedback regarding hazardous medication prescribing in primary care. A WebM&M commentary describes other pharmacy-led efforts to make prescribing safer.