This study explored associations between person-related (e.g., individual responsible for medication error), environment-related (e.g., transitions of care), and communication-related (e.g., misreading of medication order) medication errors in two Australian hospitals. The authors recommend that improved communication regarding medications with patients and families could reduce medication errors associated with possible or probable harm.

The goal of medication reconciliation is to identify medication inconsistencies at hospital discharge. This study identified six common medication reconciliation errors at discharge – duplication, missing route, missing dose, missing frequency, unlisted medication, and “see instructions” errors. The authors evaluated the prevalence of these errors at two pediatric hospitals and found that duplication and “see instructions” errors were most common. 

Implementing effective interventions supporting medication reconciliation is an ongoing challenge. Using qualitative data, the authors explored how different hospitals implemented one evidence-based medication reconciliation toolkit. Thematic analyses suggest that the most commonly used implementation strategies included restructuring (e.g., altered staffing, equipment, data systems); quality management tools (e.g., audit and feedback, advisory boards); thorough planning and preparing for implementation; and education and training with stakeholders.

Community pharmacists play an important role in patient safety. In this longitudinal study, community pharmacists reported 1,013 medication incidents, mainly at the prescribing and dispensing stages. Recommended prevention strategies included improved patient safety culture, adherence to organizational policies and procedures, and healthcare provider education.

This systematic review explored how artificial intelligence (AI) based on machine learning algorithms and natural language processing is used to address and report patient safety outcomes. The review suggests that AI-enabled decision support systems can improve error detection, patient stratification, and drug management, but that additional evidence is needed to understand how well AI can predict safety outcomes.  

This mixed-methods study assessed the barriers and facilitators to hospitals’ implementation of the MARQUIS toolkit, which supports hospitals in developing medication reconciliation programs. Leadership who responded to the survey/interview expressed limited institutional budgetary and hiring support, but hospitals were able to implement and sustain the toolkit by shifting staff responsibilities, adding pharmacy staff, and using a range of implementation strategies (e.g., educational tools for staff, EHR templates).

This study compared medication errors detected using incident reports, the Global Trigger Tool method, and direct observations of patient records. Incident reports and the Global Trigger Tool more commonly identified medication errors likely to cause harm. Omission errors were commonly identified by all three methods, but identification of other errors varied. For example, incident reports most commonly identified wrong dose and wrong time errors. The contributing factors also varied by method, but in general, communication issues and human factors were the most common contributors.

This study evaluated cross-sectional survey data from pharmacists and patients to characterize organizational factors associated with variation in safety climate, patient satisfaction and self-reported medication adherence in community pharmacies in the United Kingdom. Safety climate was associated with pharmacy ownership, organizational culture, working hours, and employment of accuracy checkers. Skill mix and continuity of care also influenced safety culture and quality.

Intravenous (IV) medication administration errors can cause severe patient harm. In this systematic review, researchers identified eleven studies characterizing the systemic causes of in-hospital IV medication errors. Systemic errors were identified most frequently during medication administration, prescribing and preparation, with common errors involving knowledge gaps, calculation errors, failure to double-check, and confusion between look-alike, sound-alike medications.  More research focused on IV medication safety is needed.

Heparin – a commonly used anticoagulant – is a high-risk medication and a patient safety risk to both adults and children. This study used a failure mode and effects analysis (FMEA) to prospectively analyze various steps in the preparation, use and disposal of heparin in a pediatric hospital to identify areas of improvement. The FMEA identified 233 potential failures and 737 potential causes of failure. Underlying causes of failure included mathematical errors, EHR challenges, and varying practice and operating procedures (or lack thereof). Countermeasures to address underlying causes are also addressed.

Recent guidelines from the Institute for Safe Medication Practices have warned of the risk of blood-borne disease transmission associated with insulin pen sharing in hospitalized patients and provide recommendations for safe practices.  This paper describes the impact on insulin pen sharing after the implementation of safe practice recommendations (e.g., label redesign, patient-specific bar coding on pens) at a quaternary academic medical center. Institutional efforts resulted in a less frequent pen-sharing events and a decrease in latent errors found during medication drawer audits, such as retained pens after discharge and illegible or missing label. 

The unintended consequences of computerized provider order entry and clinical decision support are well-described. Researchers conducted focus groups with pharmacists and physicians at two acute care hospitals in England and found that both computerized provider order entry and clinical decision support increased different aspects of workload for pharmacists and providers while electronic messaging capability yielded some improvements in interprofessional communication.

Although electronic prescribing has been shown to reduce prescribing errors, the impact on adverse drug events remains less certain. Overriding of drug–drug interaction alerts and inclusion of free-text notes that contain inaccurate information within electronic prescriptions suggests that safe prescribing requires more than an electronic system. To improve the safety of electronic prescribing, the authors make several broad recommendations. They suggest including drug indications on prescriptions, ensuring a readily available and accurate medication list, notifying pharmacies when previously prescribed medications are canceled, using standard prescription instructions, improving decision support, and promoting consideration of nondrug options. A previous WebM&M commentary discussed an incident involving an electronic prescribing error. The Moore Foundation provides free access to this article.

In this cross-sectional study, researchers evaluated medication safety letters issued by Health Canada, the United States Food and Drug Administration, and the United Kingdom Medicines and Healthcare products Regulatory Agency over a 4-year period to evaluate consistency of structure and content as well as timing and commonality of subject matter. They found significant differences in the medication safety letters issued by all three agencies with regard to both the timing and the focus. The authors suggest that better coordination across these bodies might improve patient safety.

Patients prescribed high-risk medications, including anticoagulants, are at increased risk for adverse drug events and may be particularly vulnerable during care transitions. This study describes how a multidisciplinary panel of anticoagulation experts used an iterative consensus-building process to determine what information should be communicated to relevant providers for all patients on anticoagulation undergoing a transition in care.

Medication reconciliation has demonstrated safety improvement in both inpatient and ambulatory settings. This commentary discusses barriers to reliably implementing medication reconciliation and attributes those challenges to the complexity of health care delivery and the costs involved in developing and sustaining a working process.

This qualitative study characterized safety hazards in medication dispensing in community pharmacies. The authors conclude that the major sources of risk pertained to interruptions and distractions, which were often exacerbated by production pressures.

This internet-based survey of pharmacists in the United Kingdom revealed an association between self-reported medication dispensing errors and higher perceived workload, similar to prior nursing studies. These findings contrast with earlier research that showed no relationship between physician working conditions and errors.

This qualitative study used interviews with community pharmacists to characterize the types of latent errors that can contribute to problems with handoffs in care. Since the handoff process was not standardized, pharmacists reported encountering both information overload and a lack of accurate information when giving and receiving handoffs.

In this analysis of responses to the AHRQ Hospital Survey on Patient Safety Culture, pharmacists who perceived a culture conducive to open communication were more likely to voluntarily report medication errors.