Vaccine errors can limit the effectiveness of immunization efforts. Based on survey data from 227 health professionals in France, this study identified several areas for improvement related to knowledge of vaccine-related errors, such as contraindications during pregnancy, vaccine storage, age-related vaccine schedules, and vaccine administration.

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.

Computerized provider order entry (CPOE), clinical decision support (CDS), and electronic medication management systems (EMMS) have increased efficiency and reduced prescribing errors, but poor design may introduce new safety hazards. Human factors and safety analysis methods can be used to increase the safety of new technologies, ideally before problems arise. This review identifies human factors and safety analysis methods applied to EMMS. Most methods focused on usability or design, and only one used a safety-oriented approach. Increased inclusion of human factors specialists could increase the use of safety-oriented methods of EMMS design.

The patient safety movement recognizes that most errors occur at the system level, not the individual level, and therefore uses a systems approach toward improving patient safety. A similar systems approach can be used by pharmacy programs to enhance the education of pharmacy students. This article describes the sociotechnical framework of healthcare (structures, processes, outcomes) and parallels with pharmacy programs.

Although direct-acting oral anti-coagulants (DOACs) are considered safer than warfarin, DOAC dosing is complex and can lead to medication errors. This narrative review discusses the clinical consequences of potentially inappropriate inpatient prescribing of DOACs and how pharmacists and anticoagulant stewardship programs can optimize inpatient DOAC treatment.

Polypharmacy among older adults can cause adverse health outcomes as well as adversely impact social outcomes, medication management, and healthcare utilization. The COFRAIL cluster randomized trial explored whether family conferences can promote deprescribing and reduce adverse outcomes related to polypharmacy in community-dwelling frail older adults. After 12 months of follow-up, the researchers did not find any significant difference in hospitalizations among patients randomized to family conferences or usual care. The number of potentially inappropriate prescriptions decreased among patients randomized to family conferences at 6-month follow-up, but this reduction was not sustained at the 12-month follow-up.

Patients are particularly vulnerable to medication errors during transitions of care, such as hospital discharge. Based on clinical judgement from four experts assessing 81 cases involving medication errors at discharge, the authors estimated that between 61-85% would result in additional healthcare utilization (e.g., additional prescriptions, primary care or ED visits, hospital or ICU admissions) and additional costs.

Minoritized and vulnerable people often experience delays in care due to systemic biases. This survey study examined the association between perceived discrimination at community pharmacies and foregoing or delaying picking up medications. Participants reported discrimination based on race, age, sexual orientation, ethnicity, income, and prescription insurance; those participants were more likely to delay picking up their medications. There was no association with discrimination and foregoing medications.

The Enhancing Quality of Prescribing Practices for Older Adults in the Emergency Department (EQUIIPPED) program is a multicomponent intervention intended to reduce potentially inappropriate medication (PIM) prescribing among older adults who are discharged from the emergency department (ED). This cluster-randomized trial set at eight Veterans Health Administration (VA) EDs compared the impact of two approaches to the audit and feedback component of the intervention – active provider feedback using academic detailing (i.e., educational outreach visits to improve clinical decision making) versus passive provider feedback using dashboard based on the Beers criteria. Researchers found that academic detailing significantly improved PIM prescribing compared to sites using the dashboard, but noted that dashboard-based audit and feedback may be a reasonable strategy EDs with limited resources.

Simulated hospital rooms have been used in medical education to identify potential safety threats. In this study, pharmacy students participated in a team-based simulation to identify potential latent errors and then completed a system thinking survey. Survey results indicated students had a good understanding of systems thinking, but only identified about half of the potential errors in the simulated room.

In medical education, the “hidden curriculum” refers to the influence of offhand comments, behaviors, and attitudes of senior clinicians on the formation of a student’s professional identity. This scoping review identified five papers examining the hidden curriculum in pharmacy education. The studies identified several approaches to address the hidden curriculum during pharmacy training, such as better integration of formal and informal training activities, encouraging positive mentor:mentee relationships between students and practicing pharmacists, and cultivating professionalism.

Implementing successful interventions to support effective medication reconciliation is an ongoing challenge. The MARQUIS2 study examined whether system- and patient-level interventions plus physician mentors can improve medication reconciliation and reduce medication discrepancies. This analysis based on patient exposure in the MARQUIS2 study found that patient receipt of a best possible medication history (BPMH) in the emergency department and medication reconciliation at admission and discharge were associated with the largest reductions in medication discrepancy rates.