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.

Ensuring patients have an understanding of their diagnoses and care plan is a critical component of patient engagement and can improve safety. Using semi-structured phone interviews and electronic health record (EHR) review, this study examined patient understanding about their inpatient care and discharge plan. Although the majority of patients (>90%) felt confident in their knowledge of their diagnosis and treatment plan, chart review indicated that only 43% to 64% correctly recalled details about their diagnosis, treatment, post-discharge treatment plan, and medication changes.

Medication errors can happen at any step along the medication pathway, from ordering to administration. This study focuses on ordering errors reported to the AHRQ Network of Patient Safety Databases (NPSD) from 2010 to 2020. The most common categories of ordering errors were incorrect dose, incorrect medication, and incorrect duration; nearly 80% of errors were definitely or likely preventable.

The goal for health care organizations to attain high reliability is established but elusive. This article shares insights drawn from a Veterans’ Health system effort to support high reliability. The approach used centered on five components focusing on leadership, data systems, implementation, training, and safety culture.

Missteps in the labeling and registration of child injury as abuse can result in harm for patients and families. This article discusses the impact of implicit bias on reporting actions and shares tactics to minimize the influence of cognitive error on recognizing and reporting of child mistreatment.

Variations in diagnostic process application reduce the safety of care. This commentary discusses how clinician engagement, community partnerships, and connected care (e.g., telehealth) should interface to improve diagnosis for patients impacted by disparities and implicit bias.

Learning from mistakes is an essential component of medical and nursing education. This retrospective study examined medical errors and near-misses committed by nursing students at more than 200 prelicensure programs. Of the 1,042 errors and near-misses reported, medication errors were most common (59%). Three primary contributing factors to errors and near-miss events were identified – (1) not checking patient identification, (2) not checking a patient’s allergy status, and (3) not following the “rights” of medication administration.

Healthcare workers are at high risk of violence from patients, caregivers, and other healthcare workers. Researchers used three systems thinking methods (ActorMap, AcciMap, and PreventiMap) and stakeholder input to identify factors contributing to work-related violence incidents and interventions that can prevent or mitigate work-related violence.

Speaking up behaviors among healthcare workers is indicative of psychological safety and a culture of safety. This survey of healthcare staff working at seven sites across one hospital network in Australia found that speaking up behaviors are influenced by whether staff feel empowered in their roles and supported by their peers and supervisors.

Medication errors are common, especially among medical trainees. This retrospective cohort study conducted at one medical center in the Netherlands identified a high rate of errors in prescriptions written by medical students (40% of all prescriptions). The most common type of error was inadequate information in the prescription – such as not indicating the dosage form or concentration, or missing usage instructions, or omitting the weight for a pediatric patient. Findings indicate that 29% of errors would not have been intercepted and resolved by an electronic prescribing system or pharmacist.

In situ simulation is a valuable way to uncover latent safety threats (LTS) when implementing new workflows or care locations. This study reports on one New York state emergency department’s in situ simulation of airway control for COVID-19 patients. Across three cycles of Plan-Do-Study-Act, numerous LSTs were identified and resolved. Quarterly airway management simulations have continued and have expanded to additional departments and conditions, suggesting the sustainability of this type of quality improvement project.

The COVID-19 pandemic led to unprecedented numbers of patients seen in the emergency department (ED), some who had COVID-19, some who had a different diagnosis, and some who had both. This study analyzes patients who presented to the ED with COVID-19 and signs of another diagnosis that was missed. Approximately one-third of patients with a second concurrent diagnosis experienced a diagnostic delay. Factors that may have influenced the missed diagnosis include ED overcrowding and anchoring heuristics.

Due to the infectious and deadly nature of COVID-19, heath care facilities were forced to change many of their person-centered policies, including restriction on visits from family and friends. This review highlights factors that impacted hospitalized patients during COVID-19. Thirty-two studies were identified and classified into three main factors: concern about the patient’s well-being during hospitalization, communication and interaction between patients, families, and care team, and the impact on the health care organization.

Patients with diabetes may not be aware of their condition and therefore may not seek timely care. In this pilot study, patients presenting to the emergency department at risk of type 2 diabetes were flagged by the electronic health record. Clinicians could then add hemoglobin A1c (HbA1c) to scheduled blood draws. Of the patients with elevated HbA1c levels contacted by study staff, three-quarters were not aware of a previous diabetes diagnosis.

Patients with mental illness may receive lower quality healthcare care than patients without mental illness. In this review of implicit and explicit biases of healthcare providers, the majority demonstrated unfavorable clinical decisions towards patients with mental illness. A prior WebM&M describes how diagnostic overshadowing of a patient with substance use disorder led to undertreatment of a cardiovascular condition.

In 2017, England’s National Health Service (NHS) implemented the Learning from Deaths program which requires NHS Secondary Care Trusts (NSCT) to report, investigate, and learn from potentially preventable deaths. This study focuses on what NCSTs learned during the first three years of the program, the actions taken in response and their impact, and engagement with Learning from Deaths. Trusts appear to have varied understanding and use of the term ‘learning’ and not all specified the impact their actions had on patient safety.

Hospitals, pharmacies, and organizations have developed numerous strategies to prevent look-alike/sound-alike medication mix-ups, but these errors continue to occur. This article suggests a human factors approach by changing the shape of the container for each medication class-type, thus reducing clinicians’ cognitive load. Importantly, drug manufacturers would need to agree on container shapes to prevent confusion when drugs are ordered from different suppliers.