Look-alike, sound-alike (LASA) medicines are known contributors to drug errors. This report discusses how name and label similarities degrade care, and the actions organizations and individual practitioners can take to mitigate the potential of LASA medication errors that cause harm. The authors discuss obstacles and enablers to implementing prevention strategies.

Chain pharmacies provide prescriptions in an environment that facilitates error due to production pressures, poor error reporting, and a lack of safety culture. This feature story examines working conditions at primary retail pharmacies in the United States and draws from staff experiences, industry data and frontline evidence to illustrate the problem as a threat to patient safety.

Patient safety progress is dynamic, consistently producing evidence for application to generate improvements. This report is the fourth in a series funded by the Agency for Healthcare Research and Quality to track a prioritized set of emerging and existing safety approaches to confirm their value and effectiveness. This report will be compiled as new conclusions are formulated. Each review will be posted to the collection as they are completed. The first three Making Healthcare Safer reports, published in 2001, 2013, and 2020, have each served as a consolidated evidence source for clinicians, health system leadership, researchers, and government agencies. Chapter protocols and the results of an examination on patient and family engagement and report cards as a surgical improvement mechanism are now available. 

Drug shortages, while often discussed as a system failure, demonstrate harm at an individual level. This story highlights the work of a patient activist who was inspired by the threat to her daughter’s care posed by a lack of chemotherapy availability, to provide needed medications during system disruptions to keep patients safe.

Process disconnects can cause administration mistakes that lead to harm. This article discusses reasons for holding medications and how workflow issues can contribute to medication temporary stop order problems. Recommendations for improvement include examining electronic health record alerts, assigning one prescriber to oversee medication reconciliation, and instituting a policy on hold orders.

Despite the harm that failure can cause, its value as a learning opportunity, if examined through the lens of human error rather than blame, cannot be understated. This book explores how failure that happens in new situations provides new insights toward goal achievement, utilizes knowledge and capitalizes on even small missteps, and can enhance and inform improvement.

Medication reconciliation should be completed at admission, discharge, and during transitions of care. This article describes the impacts of pharmacist involvement, including lower hospital readmissions and post-discharge adverse events.

The lack of a safety culture fundamentally restricts the ability of clinicians to address mistakes, psychologically deal with them and learn. The CANDOR system is highlighted in this presentation by one of the originators of the concept as a strategy for successful resolution, learning and support for those involved in medical error.

A wide variety of considerations must converge to inform an understanding of system vulnerabilities and the application of strategies to address them. This series of webinars covers a range of topics affecting the reliability of the health care environment.  A recent presentation discussed the “5 rights of medication safety.”