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Procaccini D, Kim JM, Lobner K, et al. Jt Comm J Qual Patient Saf. 2022;48:154-164.
Weight-based medication dosing is a common source of medication errors in children. This systematic review identified limited evidence that overweight and obese children maybe be at increased risk of weight-based medication dosing errors, but the authors note that the clinical significance is unknown.
Carvalho IV, Sousa VM de, Visacri MB, et al. Pediatr Emerg Care. 2021;37:e152-e158.
This study sought to determine the rate of pediatric emergency department (ED) visits due to adverse drug events (ADE). Of 1,708 pediatric patients, 12.3% were admitted to the ED due to ADEs, with the highest rates of admission due to neurological, dermatological, and respiratory medications. The authors recommend the involvement of clinical pharmacists to prevent and identify ADEs in the pediatric population, particularly through education of children’s caregivers and health professionals.
Lerner JE, Martin JI, Gorsky GS. Sex Res Social Pol. 2020;18:409-426.
This study used national survey data to examine avoidance of healthcare services among transgender, gender nonconforming, and non-binary people. Researchers found that nearly one quarter of respondents reported not seeking healthcare when necessary because they anticipated being disrespected or mistreated by healthcare professionals. Previous experience with certain discriminatory behavior such as invasive questions, refusal of care, verbal harassment, as well as cost and needing to educate providers, were strong predictors of healthcare avoidance.
Elliott RA, Camacho E, Jankovic D, et al. BMJ Qual Saf. 2021;30:96-105.
This study combined previously published error prevalence estimates in the United Kingdom to estimate the annual number and burden of medication errors to the National Health Service (NHS). The authors estimate that 237 million medication errors occur annually in the UK. The majority of errors occur during medication administration and prescribing and occur most frequently in long-term care and primary care settings. While the majority of errors have little or no potential for harm, 66 million errors were deemed potentially clinically significant; prescribing in primary care settings accounts for one-third of these potentially significant errors. These medication errors result in hospital admissions or longer length of stay, as well as death. 
Herledan C, Baudouin A, Larbre V, et al. Support Care Cancer. 2020;28:3557-3569.
This systematic review synthesizes the evidence from 14 studies on medication reconciliation in cancer patients. While the majority of studies did not include a contemporaneous comparison group, they did report that medication reconciliation led to medication error identification (most frequently drug omissions, additions or dosage errors) in up to 88-95% of patients.
Davies LE, Spiers G, Kingston A, et al. J Am Med Dir Assoc. 2020;21:181-187.
In this systematic review, the authors synthesized evidence on polypharmacy in older adults and subsequent adverse health outcomes, as well as impacts on social outcomes (e.g., loneliness), medication management (e.g., nonadherence) and healthcare utilization. Results from twenty-six reviews encompassing 230 unique studies showed that polypharmacy is associated with increased hospitalizations and inappropriate prescribing. The authors describe conflicting evidence on associating polypharmacy with adverse outcomes, including adverse drug events and disability. Evidence on the adverse social outcomes, as well as harms in adults 85 years and older, was limited.
Crannage AJ, Hennessey EK, Challen LM, et al. Ann Pharmacother. 2020;54:561-566.
Pharmacists play an important role in patient safety, particularly bridging transitions of care between inpatient and outpatient settings. This study assessed the impact of a discharge medication education program for high-risk patients, including scheduling a post-hospital discharge telephone follow-up within 2 days of discharge. This intervention increased the number of patients who were successfully contacted post-discharge (from 20% pre-intervention to 78%) and seen in clinic within 14-days (from 49% to 60%) and reduced the 30-day readmission rate (from 19% to 10%).
Bloodworth LS, Malinowski SS, Lirette ST, et al. Journal of the American Pharmacists Association: JAPhA. 2019;59:896-904.
Medication reconciliation is one potential strategy for preventing adverse events and readmissions. This study examined a pharmacist-led intervention involving collaborations with inpatient and community-based pharmacists to provide pre-discharge and 30-day medication reconciliation. There were indications that this type of intervention can reduce readmission rates, but further investigation in larger populations is necessary.  
Pellegrin K, Lozano A, Miyamura J, et al. BMJ Qual Saf. 2019;28:103-110.
Older adults frequently encounter medication-related harm, which may result in preventable hospitalizations. In six Hawaiian hospitals, hospital pharmacists identified older patients at risk of medication problems and assigned them to a community pharmacist who coordinated their medications across prescribers for 1 year after discharge. This post-hoc analysis of the intervention found that most medication-related harm occurred in the community (70%) rather than the hospital and that the intervention successfully reduced community-acquired harm.
Watts RG, Parsons K. Pediatr Blood Cancer. 2013;60:1320-4.
A multidisciplinary, pharmacy-associated intervention halved the number of pediatric chemotherapy errors at a single institution (from 3.9 to 1.8 per 1000 medications dispensed) but failed to achieve its goal of a Six Sigma error rate.
Setter SM, Corbett CF, Neumiller JJ, et al. Am J Health Syst Pharm. 2009;66:2027-31.
A medication reconciliation intervention conducted by a pharmacist and nurse significantly reduced the number of medication errors at hospital discharge, but did not affect readmission rates or the need for return physician visits.
Snow V, Beck D, Budnitz T, et al. J Gen Intern Med. 2009;24:971-976.
This policy statement describes ten principles developed to address quality gaps in transitions of care between inpatient and outpatient settings. Recommendations include coordinating clinicians, having a transition record, standardizing communication formats, and using evidence-based metrics to monitor outcomes.
Cohen MR.
This monthly selection of medication error reports describes a case of misidentifying home medications for a hospitalized patient, how character space limitations in medication administration records may cause medication errors, and fatal misuse of a fentanyl patch on a child.