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Kelman B. Kaiser Health News. April 29, 2022.

Technological solutions harbor unique risks that can result in patient harm. This article shares a response to reports of automated dispensing cabinet (ADC) menu selection limitations that contribute to mistakes. The piece suggests the implementation of a 5-letter search requirement prior to removing a medication from an ADC. It provides an update on industry response to this forcing function recommendation.
Colombini N, Abbes M, Cherpin A, et al. Int J Med Inform. 2022;160:104703.
Computerized provider order entry (CPOE) refers to a system in which clinicians directly place orders electronically to be sent to the receiver (e.g., pharmacist). This French hospital analyzed hospital discharge orders (HDO) over a six-month period to evaluate the use rate of CPOE, prescription concordance between CPOE-edited HDO, exit prescriptions transcribed in the discharge summary, and prescribing error rate. Use of CPOE and pharmacist intervention reduced prescribing errors of hospital discharge orders.
Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.
This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety. In addition, it covers safe practices when technologies are not available.
Lin MP, Vargas-Torres C, Shin-Kim J, et al. Am J Emerg Med. 2022;53:135-139.
Drug shortages can result in patient harm, such as dosing errors from a medication substitution. In this study, 28 of the 30 most frequently used medications in the emergency department experienced shortages between 2006 and 2019. The most common reasons for shortages were manufacturing delays and increased demand. The COVID-19 pandemic exacerbated pre-existing drug shortages.
Uitvlugt EB, Heer SE, van den Bemt BJF, et al. Res Soc Admin Pharm. 2022;18:2651-2658.
Pharmacists play a critical role in medication safety during transitions of care. This multi-center study found that a transitional pharmacy care program (including teach-back, pharmacy discharge letter, home visit by community pharmacist, and medication reconciliation by both the community and hospital pharmacist) did not decrease the proportion of patients with adverse drug events (ADE) after hospital discharge. The authors discuss several possible explanations as to why the intervention did not impact ADEs and suggest that a process evaluation is needed to explore ways in which a transitional pharmacy care program could reduce ADEs.
Lohmeyer Q, Schiess C, Wendel Garcia PD, et al. BMJ Qual Saf. 2022;Epub Mar 8.
Tall Man lettering (TML) is a recommended strategy to reduce look-alike or sound-alike medication errors. This simulation study used eye tracking to investigate how of ‘tall man lettering’ impacts medication administration tasks. The researchers found that TML of prelabeled syringes led to a significant decrease in misidentified syringes and improved visual attention.

Am J Health Syst Pharm. 2022;79(7): 564-599.

Pharmacists have a central role in ensuring medication safety during healthcare delivery. This report outlines standards for the delivery of safe, high-quality pharmacy services including how pharmacy departments should be placed within the health system and how health system processes can support safe medication use and pharmacy practice.
Hall N, Bullen K, Sherwood J, et al. BMJ Open. 2022;12:e050283.
Reporting errors is a key component of improving patient safety and patient care. Primary care prescribers and community pharmacists in Northeast England were interviewed about perceived barriers and enablers to reporting medication prescribing errors, either internally or externally. Motivation, capability, and opportunity influenced reporting behaviors. 
Van De Sijpe G, Quintens C, Walgraeve K, et al. BMC Med Inform Decis Mak. 2022;22:48.
Clinical decision support systems (CDSS) can help identify potential drug-drug interactions (DDI), but they can lead to alert fatigue and threaten patient safety. Based on an analysis of DDI alerts and survey data regarding physician experience using the DDI module in the CDSS, researchers identified barriers (i.e., lack of patient-specific characteristics and DDI-specific screening intervals) that contribute to false-positive alerts and alert fatigue.

Institute for Safe Medication Practices.

Workplace bullying and disrespectful behavior have been shown to negatively affect fall rates, medication errors, and other adverse events. The Institute for Safe Medication Practices is seeking clinician input on and experiences with disrespectful behaviors in the ambulatory care setting (e.g., community, specialty, and long-term care pharmacies, physician practices, and outpatient visits) and how organizations have been working to improve the culture of respect. The survey will be open until May 27, 2022.
Reese T, Wright A, Liu S, et al. Am J Health Syst Pharm. 2022;79:1086-1095.
Computerized decision support alerts for drug-drug interactions are commonly overridden by clinicians. This study examined fifteen well-known drug-drug interactions and identified risk factors that could reduce risk in the majority of interactions (e.g., medication order timing, medication dose, and patient factors).

Errors in medication management and administration are major threats to patient safety. This piece explores issues with opioid and nursing-sensitive medication safety as well as medication safety in older adults. Future research directions in medication safety are also discussed.

Kukielka E, Jones R. Patient Safety. 2022;4:49-59.
Medication errors can occur in all clinical settings, but can have especially devastating results in emergency departments (EDs). Between January 1, 2011, and December 31, 2020, 250 serious medication errors occurring in the ED were reported to the Pennsylvania Patient Safety Reporting System. Errors were more likely to occur on weekends and between 12:00 pm and midnight; patients were more likely to be women. Potential strategies to reduce serious medication errors (e.g., inclusion of emergency medicine pharmacists in patient care) are discussed.

March KL, Peters MJ, Finch CK, et al. J Pharm Pract. 2022;35(1):86-93.

Transitions of care from inpatient to outpatient settings are vulnerable to medication errors. This study found that patients receiving pharmacist-led medication reconciliation and education prior to discharge reported higher patient satisfaction scores; lower readmission rates compared to standard care patients were also observed. Pharmacists potentially prevented 143 medication safety events during medication reconciliation.
LaScala EC, Monroe AK, Hall GA, et al. Pediatr Emerg Care. 2022;38:e387-e392.
Several factors contribute to pediatric antibiotic medication errors in the emergency department, such as the frequent use of verbal orders and the need for  weight-based dosing. Results of this study align with previous research and reinforce the need for further investigation and interventions to reduce antibiotic medication errors such as computerized provider order entry.
McGinty EE, Bicket MC, Seewald NJ, et al. Ann Intern Med. 2022;175:617-627.
Prior research has found that unsafe opioid prescribing practices are common. This retrospective study explored the association between state opioid prescribing laws and trends in opioid and nonopioid pain treatment among commercially insured adults in the United States. Findings suggest that these laws were not associated with statistically significant changes in prescribing outcomes, but the authors note that some of these estimates were imprecise and may not be generalizable to non-commercially insured populations.
Irons MW, Auta A, Portlock JC, et al. Home Health Care Serv Q. 2022;41:91-123.
Care home residents experience high rates of medication errors. Thirty-two articles about medication errors in UK care homes were included in this review. Articles covered causes, rates, recommendations, and/or evaluation of interventions on error rates. The authors recommend development of more robust strategies for evaluating medication errors in care homes.
Watterson TL, Stone JA, Gilson A, et al. BMC Med Inform Decis Mak. 2022;22:50.
The CancelRx system is a health information technology-based intervention intended to mitigate the challenges of communicating medication discontinuation. Using secondary data from the electronic health record (EHR) system of a midwestern academic health system, researchers found that implementing the CancelRx system resulted in a significant increase in successful medication discontinuations for controlled substances.
Zhu J, Weingart SN. UpToDate. Mar 18, 2022.
Unsafe medication systems in hospitals can lead to adverse drug events (ADEs). This review discusses patient care and organizational factors that contribute to ADEs, methods to detect medication errors, and prevention strategies such as medication reconciliation and enhanced pharmacist participation.