An increasing strategy to reduce adverse drug events (ADE) is pharmacist medication review, typically involving other members of the care team. This qualitative review summarizes randomized studies of interventions with multidisciplinary care teams to reduce ADE. Most interventions were time-intensive (1- to 2-hours), including four steps (data collection, appraisal report, multidisciplinary medication review, follow up). Most teams consisted of a pharmacist, physician, and nurse, although some included other providers such as psychologists or social workers.

Improving medication safety in ambulatory care settings is a patient safety priority. This qualitative study with primary care teams across four sites in the southwestern United States explored approaches to improving medication safety. Respondents emphasized the importance of customization and individualization (e.g., simplifying medication regimens for certain patients) and described how the principles of high reliability can help teams anticipate and respond to medication safety risks.

Polypharmacy is a common patient safety concern among veterans. In this study, 21 Veterans Health Administration (VA) sites developed their own deprescribing protocols and participated in a virtual deprescribing collaborative. Sites employed decision support tools, such as the VA VIONE tool, and other strategies, such as individualized medication review, to encourage deprescribing and reduce polypharmacy among its patients.

STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert to Right Treatment) criteria are used to identify potentially inappropriate prescribing in older adults. This article describes the consensus process to update and validate the third version of the STOPP/START criteria using evidence from a systematic review and input from a panel with expertise in geriatric pharmacology. The consensus process resulted in additional STOPP criteria (133 versus 80 in version 2) and START criteria (57 versus 34 in version 2). The additional criteria in version 3 can help clinicians detect and prevent adverse drug-drug and drug-disease interactions.

Potentially inappropriate prescribing in long-term care facilities increases the risk of adverse drug events and other adverse outcomes, including increased healthcare costs. Based on a secondary data analysis from the Systematic Dementia Screening by Multidisciplinary Team Meetings in Nursing Homes for Reducing Emergency Department Transfers (IDEM) randomized trial, this study found that increases in potentially inappropriate prescribing increased residents’ risk of going to the emergency room and increased total medication spending.

Community pharmacists are perhaps the last line of defense in preventing medication errors in the outpatient setting; therefore, ensuring a strong safety culture is critical. This review identified 11 studies reporting on safety culture using the AHRQ Community Pharmacy Survey on Patient Safety Culture. Pharmacists and pharmacy staff rated overall patient safety highly, but more than half identified workload as a concern.

Deprescribing is used to reduce the risk of adverse drug events resulting from polypharmacy among older adults. This article outlines several recommendations for improved cost-effectiveness analyses of deprescribing interventions to support decision makers.

Medication reconciliation can help providers identify potential safety issues during medication administration. Based on interviews with stakeholders, this study examined medication reconciliation practices across Canadian cancer centers. Although a high proportion of the centers had a process for collecting best possible medication history (BPMH, 81%), implementation of a complete medication reconciliation process was uncommon. Stakeholders identified several barriers to implementation, including lack of resources and a lack of electronic health record interoperability across institutions, systems, and community pharmacies.

Older patients are particularly vulnerable to harm during hospitalization. This article summarizes potential patient harm that can occur during hospitalization for older adults, including unnecessary testing or procedures, nosocomial infections, medical errors, falls, functional or cognitive decline, and post-discharge adverse events.

Polypharmacy in older adults increases the risk of potentially inappropriate medications (PIM) and potential drug-drug interactions (PDI). This secondary analysis of a national study of older adults with advanced cancer sought to identify associations between polypharmacy (eight or more medications), PIMs, and PDIs with adverse cancer treatment outcomes. Polypharmacy and PDIs were associated with increased risk of adverse treatment outcomes, but PIMs were not.

Direct oral anticoagulant (DOAC) dosing is complex and can lead to medication errors. This analysis of 15,730 incident reports involving DOACs reported in the United Kingdom between 2017 and 2019 found that the majority (87.6%) were due to active failures and 2.2% resulted in moderate/severe harm or death. This PSNet WebM&M commentary discusses approaches to improving safety when prescribing DOACs.

Children with medical complexity (CMC) frequently take multiple medications, often from multiple prescribers. This commentary describes the particular vulnerabilities CMC face throughout the medication use cycle, along with ways for the prescriber and system to mitigate the risks of polypharmacy.

Community-based pharmacists have a critical role in ensuring medication safety in community settings. In this narrative review, the authors explored how collaboration between community-based pharmacists and primary care providers can improve medication safety. The most common collaboration strategy was medication review. The authors identified barriers to collaboration from both the primary care provider and pharmacist perspectives.

Missed diagnosis of infectious diseases can have serious consequences for patient safety. This article describes a delayed diagnosis of disseminated tuberculosis in a patient with lung cancer and discusses the how cognitive biases and systems failures contributed to the diagnostic error.

Inadequate or incorrect documentation of patient allergies can lead to patient harm. This commentary discusses factors contributing to penicillin allergy documentation errors within electronic heath record systems (EHRs) and how EHR alerts can be used to improve safety around penicillin allergies.

Prior research has found that electronic health record (EHR) implementation has introduced risks to patient safety. Using data from one hospital’s EHR system, this study reviewed active allergy alerts in patient records and concluded that 37% of those records required reconciliation of allergy information across different areas of the EHR. These findings highlight the need for automated reconciliation algorithms and clinical decision support tools to help clinicians identify potential allergy discrepancies and avoid patient safety risks.

Patient exposure to allergens healthcare settings, such as latex or certain medications, can lead to adverse outcomes. Based on data from an incident reporting system, researchers in this study developed a system for classifying allergy-related safety events. Classification categories include: (1) incomplete or inaccurate EHR documentation, (2) human factors, such as overridden allergy alerts, (3) alert limitation or malfunction, (4) data exchange and interoperability failures, and (5) issues with EHR system default options. This classification system can be used to support improvements at the individual, team, and systems levels.