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Huynh I, Rajendran T. BMJ Open Qual. 2021;10:e001363.
Unintentional therapeutic duplication can lead to life-threatening complications. As part of a quality improvement project on a surgical ward, staff were educated about the risks of therapeutic duplication and strategies to decrease it. After one month of education and reminders, the rate of therapeutic duplication decreased by more than half.
Koeck JA, Young NJ, Kontny U, et al. Pediatric Drugs. 2021;23:223-240.
Pediatric patients are at risk for medication prescribing errors due to weight-based dosing. This review analyzed 70 interventions aimed at reducing weight-based prescribing errors. Findings indicate that bundled interventions are most effective, and that interventions should include substitute or engineering controls (e.g., computerized provider order entry) along with administrative controls (e.g., expert consultation).
Alshahrani F, Marriott JF, Cox AR. Int J Clin Pharm. 2020;43:884-892.
Computerized provider order entry (CPOE) can prevent prescribing errors, but patient safety threats persist. Based on qualitative interviews with multidisciplinary prescribers, the authors identified several issues related to CPOE interacting within a complex prescribing environment, including alert fatigue, remote prescribing, and default auto-population of dosages.

Phipps D, Ashour A, Riste L, et al. The Pharmaceutical Journal. 2020;305(7943, 7944). November 10, December 1, 2020.

Dispensing mistakes are a common contributor to preventable adverse events in community pharmacies. Part 1 of this two-part series discusses factors that contribute to dispensing errors and summarizes methods for managing risks stemming from missteps. Part 2 focuses on preventing situations that enable errors and the role pharmacists have in minimizing dispensing errors in daily practice.

Farnborough, UK: Healthcare Safety Investigation Branch; September 24, 2020. 

Unit-based pharmacy services help to mitigate and catch medication errors. This report highlights a case of a medication error death and describes how embedding clinical pharmacy services could have prevented this incident. The report provides system level recommendations to enhance this service including defining the role of clinical pharmacy teams and prioritizing the tactic as an important improvement strategy.   
Härkänen M, Turunen H, Vehviläinen-Julkunen K. J Patient Saf. 2020;16.
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.
Jacobs S, Hann M, Bradley F, et al. Res Soc Admin Pharm. 2020;16:895-903.
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.
Farnborough, UK: Healthcare Safety Investigation Branch; 2019.
Design flaws and improper use of technologies that transfer medication and prescription information between provider environments is a known threat to patient safety. This report analyzes an anticoagulant overdose incident and found that information technology missteps contributed to the error.
Bain A, Silcock J, Kavanagh S, et al. BMJ Open Qual. 2019;8:e000655.
Medication errors involving insulin are common, particularly in hospitals and at point-of-care transfers. Using a continuous improvement methodology, a multidisciplinary project team carried out three “plan-do-study-act" cycles to introduce locally tailored insulin discharge prescribing guidance. Adherence to the guidelines improved from an average of 50% to 99% after introduction of a poster and then checklist forms of the guidelines. This small, qualitative study in one hospital diabetes ward suggests that small iterative changes can improve insulin discharge prescription quality. A PSNet primer expands on the topic of medication reconciliation. 
Ardenne M, Reitnauer PG. Arzneimittel-Forschung. 1975;25:1369-79.
This special issue reviews research initiatives exploring persistent challenges associated with the prescription drug misuse epidemic and strategies to monitor and reduce its persistence. Topics covered include the role of the pharmacist in addressing opioid misuse, physician–pharmacist collaboration to improve pain management, and community pharmacy monitoring of opioid dispensing.
Pontefract SK, Coleman JJ, Vallance HK, et al. PLoS One. 2018;13:e0207450.
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.
Vélez-Díaz-Pallarés M, Pérez-Menéndez-Conde C, Bermejo-Vicedo T. Am J Health Syst Pharm. 2018;75:1909-1921.
Use of computerized provider order entry (CPOE) is increasingly widespread. This systematic review found that while CPOE with clinical decision support reduced certain medication errors associated with prescribing, CPOE led to the introduction of new errors.
Bjerre LM, Parlow S, de Launay D, et al. BMJ Open. 2018;8:e020150.
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.
Liu F, Abdul-Hussain S, Mahboob S, et al. Int J Clin Pharm. 2014;36:827-34.
Elderly patients are particularly vulnerable to adverse drug events. This analysis found that the majority of medication information leaflets were difficult for older patients to read and interpret. Similar problems have been found with medication labels.
Harvey J, Avery AJ, Ashcroft D, et al. Res Social Adm Pharm. 2015;11:216-27.
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.
Johnson SJ, O'Connor EM, Jacobs S, et al. Res Social Adm Pharm. 2014;10:885-895.
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.