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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.  
National Pharmacy Association; NPA.
This website for independent community pharmacy owners across the United Kingdom features both free and members-only guidance, reporting platforms, and document templates to support patient safety. It includes reporting tools and incident analysis reports for providers in England, Scotland, and Northern Ireland. Topics covered in the communications include look-alike and sound-alike drugs, patient safety audits, and safe dispensing of liquid medications.
Cheong V-L, Tomlinson J, Khan S, Petty D. Prescriber. 2019;30:29-34.
Geriatric patients are particularly vulnerable to medication-related harm. This article summarizes types of incidents and contributing factors to adverse drug events in older patients after hospital discharge. The authors recommend strategies to reduce medication-related harm, including discharge communication improvements, primary care collaboration, and postdischarge patient education.
Seen in the emergency department, a man with insulin-dependent diabetes mellitus had not taken insulin for 3 days. His blood glucose levels were in the 800s with an anion-gap acidosis and positive beta hydroxybutyrate. While awaiting an ICU bed for treatment of diabetic ketoacidosis, the patient received fluids, an insulin drip was started, and blood glucose levels were monitored hourly. When lab results showed he was improving, the team decided to convert his insulin drip to subcutaneous long-acting insulin.
Craynon R, Hager DR, Reed M, et al. Am J Health Syst Pharm. 2018;75:1486-1492.
Pharmacists are expanding their reach as stewards of medication safety into the front line of care. This project report describes the pilot testing of pharmacist involvement in development and review of medication orders in the discharge workflow. A substantive percentage of medication problems were prevented due to pharmacist engagement.
Triller D, Myrka A, Gassler J, et al. Jt Comm J Qual Patient Saf. 2018;44:630-640.
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.
Abebe E, Stone JA, Lester CA, et al. J Patient Saf. 2021;17:405-411.
Handoffs present a significant patient safety hazard across multiple health care settings. Interruptions and distractions, which can interfere with handoff communication, are prevalent in pharmacy environments. This cross-sectional survey of community pharmacies found that virtually none of the pharmacists had received training in how to hand off information. A significant proportion of responses indicated that pharmacy information technology systems do not support handoff communication. Respondents reported that handoffs are frequently inadequate or inaccurate. The authors conclude that interventions are needed to enhance the quality of handoff communication in community pharmacy settings to prevent dispensing errors.
An elderly man on warfarin and aspirin for chronic atrial fibrillation and previous cerebrovascular accident presented to the emergency department with a severe headache. Found to have bilateral subdural hematomas and a supratherapeutic INR (4.9), he was admitted to the ICU. Even though the patient was discharged with his warfarin discontinued permanently, the outpatient pharmacy kept it on the active medication list and refilled his mail order prescription automatically, leading again to an elevated INR.
Following a hospitalization for Clostridium Difficile–associated diarrhea, a woman with HIV/AIDS and B-cell lymphoma was discharged with a prescription for a 14-day course of oral vancomycin solution. At her regular retail pharmacy, she was unable to obtain the medicine, and while awaiting coverage approval, she received no treatment. Her symptoms soon returned, prompting an emergency department visit where she was diagnosed with toxic megacolon.
Martin ES, Overstreet RL, Jackson-Khalil LR, et al. Am J Health Syst Pharm. 2013;70:18-21.
This commentary details the development of a medication reconciliation program to improve documentation at discharge, which included identifying high-risk drugs, forming a team of three full-time pharmacists, and tracking patients with pending discharges.
Lee JY, Leblanc K, Fernandes OA, et al. Ann Pharmacother. 2010;44:1887-95.
This study found that 62% of patients transferred between units during a hospitalization had at least one unintentional medication discrepancy. The most common discrepancy was medication omission, independent of which system was used (e.g., paper versus computerized).
Stone BL, Boehme S, Mundorff MB, et al. Arch Dis Child. 2009.
This study documents the challenges in implementing medication reconciliation in a children's hospital. Five different sources (parents, pharmacies, primary care physicians, discharge summaries, and admission histories) were used to compile admission medication lists, but all were inaccurate to varying degrees, leaving children at high risk of preventable harm.
Cohen MR, Smetzer JL. Hosp Pharm. 2010;45.
This monthly column highlights an initiative to introduce safer device connectors to prevent spinal and epidural medications from being delivered intravenously, discusses the value of independent double-checks, and shares thoughts on the 35th anniversary of this column.
Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25.
Discrepancies in patients' medications at the time of hospital admission are common. Performed at an academic medical center, this cohort study used a pharmacist-led medication reconciliation process to determine a "gold standard" medication list for newly admitted patients, identify discrepancies between patients' medication lists and the medications ordered by admitting physicians, and investigate risk factors for preventable medication errors. More than one-third of patients had at least one discrepancy, with elderly patients and patients with more complex medication regimens being at higher risk—factors also documented in prior research. Patients who presented their own medication list or pill bottles were at reduced risk. The medication reconciliation process used in this study is available as an online toolkit.
Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:847-853.
This monthly selection reports on two pediatric deaths due to severe hyponatremia following postoperative fluid administration. Errors involving a missing dose clarification request, a related near miss, and medication name confusion are also described.