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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.
Gabler E. New York Times. 2020;Jan 31.
Pharmacists are instrumental to safe medication use in the ambulatory setting. This news story discusses factors in retail pharmacy environment that degrade pharmacists’ ability to safely practice, which include production pressure, required multitasking, and distraction. Strategies highlighted to mitigate the problem that have been inconsistently applied include scheduled breaks and staff supervision limits.
Bowden A, Mullin S, Tak C, et al. Am J Health Syst Pharm. 2019;76:360-365.
Researchers examined employee perceptions of safety culture before and after implementation of a pharmacy services call center designed to reduce interruptions across nine community pharmacies. They found that pharmacies with the call centers reported a 9.3% overall improvement in patient safety after implementation.
Kellogg KM, Puthumana JS, Fong A, et al. J Patient Saf. 2021;17:e1394-e1400.
Using incident reporting data from a multihospital reporting system over a 3-year period, researchers sought to identify safety events related to interruptions. About 43% of interruption events were reported by nurses, compared to 15% by pharmacists and 7% by physicians. Interruptions most commonly involved a medication-related task.
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.
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.
Hendrickson T. AORN J. 2007;86:626-9.
This article describes the causes of medication errors in the operating room and discusses prevention strategies, including using read-back techniques and reducing interruptions.
A nurse notices that an IV medication she is about to administer is possibly mislabeled, as it looks like a different drug. However, she is interrupted before she can call the pharmacy and winds up hanging the bag anyway.