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Keller C. Health Aff (Millwood). 2022;41:1353-1356.
Communication failures due to hierarchy and silos create opportunities for adverse medication and treatment events. This narrative essay discusses gaps in care coordination that contributed to anticoagulant medication errors. The author outlines areas for improvement such as assignment of accountability for error and commitment to the learning health system as avenues for improvement.
Clabaugh M, Beal JL, Illingworth Plake KS. J Am Pharm Assoc (2003). 2021;61:761-771.
Patient safety concerns in community pharmacies have been documented in the media. This study sought to examine the association of working conditions and patient safety. Results indicate that while all participants reported negative company climate and workflow, those in chain pharmacies reported significantly more fear of speaking up about patient safety issues than those in independent, big box, or grocery pharmacies.
Adie K, Fois RA, McLachlan AJ, et al. Eur J Clin Pharmacol. 2021;77:1381-1395.
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.

Eng DM, Schweikart SJ. AMA J Ethics. 2020;22(9):e779-e783.

The recognition that humans err and the situation of response to error in a constructive and nonpunitive light are central to achieving safe patient care. This article discusses how implementation of just culture principles can assign accountability appropriately while encouraging disclosure and improvement when mistakes occur. 
Kim S, Appelbaum NP, Baker N, et al. J Healthc Qual. 2020;42:249-263.
This review summarizes studies of training programs targeting healthcare professionals’ speaking up skills. The authors found that most training programs were limited to a one-time training delivered to a single profession (i.e., limited to doctors or nurses).  The majority of programs addressed legitimate power (i.e., social norms such as titles) but few addressed other types of power (e.g., reward or coercive power, personal resources) or the non-verbal (i.e., emotional) skills required in speaking-up behaviors.  
Perea-Pérez B, Labajo-González E, Acosta-Gío AE, et al. J Patient Saf. 2020;16.
Based on malpractice claims data in Spain, the authors propose eleven recommendations to mitigate preventable adverse events in dentistry. These recommendations include developing a culture of safety, improving the quality of clinical records, safe prescribing practices, using checklists in oral surgical procedures, and having an action plan for life-threatening emergencies in the dental clinic.
Patel MR, Friese CR, Mendelsohn-Victor K, et al. J Oncol Pract. 2019;15:e529-e536.
Although electronic health records have addressed some patient safety concerns, they have also introduced new risks. In this survey study in oncology, nearly 300 individuals, including physicians, nurse practitioners, and nurses, completed a survey ranking their practice's reliance on the electronic health record (from 1= "all paper" to 5= "all electronic") and measuring safety culture and quality of clinician–clinician communication. Investigators found that individuals describing a greater degree of electronic health record use reported lower safety culture scores, and individuals who rated communication higher also perceived safety culture as more optimal. The authors suggest that challenges to electronic health record use may affect oncology practitioners' perceptions of safety. A previous PSNet interview discussed the role of health information technology in patient safety.
Desai S, Fiumara K, Kachalia A. J Patient Saf. 2021;17:e84-e90.
Outpatient safety is gaining recognition as a focus of research and improvement efforts. This project report describes an ambulatory safety program at an academic health system that targeted reporting, safety culture measurement, medication safety, and test result management. Repeated tracking over a 5-year period revealed that failure to request feedback played a role in the modest incident and concern reporting captured by the program. Decentralizing reporting response responsibilities throughout the system significantly increased feedback activity.
Phipps DL, Jones CEL, Parker D, et al. BMC Health Serv Res. 2018;18:783.
In this qualitative study, researchers followed the progress of the improvement work taken on by 10 English community pharmacies that participated in improvement workshops over a 1-year period. Using a behavioral change framework, they were able to describe the pharmacies' progress in their activities as well as identify particular organizational factors facilitating improvement work.
Jeffries M, Keers RN, Phipps DL, et al. PLoS One. 2018;13:e0205419.
Pharmacists enhance medication safety in hospitals and ambulatory settings. The authors interviewed pharmacists about their experience implementing a dashboard that allowed them to identify and provide feedback regarding hazardous medication prescribing in primary care. A WebM&M commentary describes other pharmacy-led efforts to make prescribing safer.
Aboneh EA, Stone JA, Lester CA, et al. J Patient Saf. 2020;16:e18-e24.
A culture of safety is vital to identifying, addressing, and preventing adverse events. Researchers delivered AHRQ's Community Pharmacy Survey on Patient Safety Culture to 445 Wisconsin pharmacists. Independent and clinic-based pharmacists reported a more robust safety culture compared to national chain pharmacists, as did pharmacists more familiar with their patients' care.
Aboneh EA, Look KA, Stone JA, et al. BMJ Qual Saf. 2016;25:355-63.
The Agency for Healthcare Research and Quality has developed safety culture surveys for multiple health care settings. Researchers distributed the survey to community pharmacies and found its validity to be inadequate for use in this environment. This suggests that instruments used in other settings will require significant adaptation to accurately measure patient safety in pharmacies.
Kralewski JE, Dowd BE, Heaton A, et al. Med care. 2005;43:817-825.
The study, which analyzed prescription drug error claims for 78 group practices, found both direct and indirect relationships between culture, practice structure, and medication errors. The authors believe that better care coordination can improve medication safety in the outpatient environment.