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The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.

Medication errors continue to be a worldwide patient safety challenge that requires both systems and individual practice strategies for improvement. This magazine article describes how pharmacists can address failures associated with processing, dosing, care transitions, and information sharing to prevent medication errors.

Transitions in care between inpatient and outpatient settings are an increasing concern for patient safety. Reporting on a fatal medication error that was missed by a patient's pharmacist and home health nurses, this newspaper article discusses various risks associated with hospital-to-home transitions such as insufficient case management and communication.

As they become more prevalent, electronic medical records (EMRs) are being used to improve safety in increasingly creative ways. This newspaper article reports on efforts to engage patients in reviewing their medication lists by providing them with access to EMR systems in order to detect and correct discrepancies in data.

This newsletter article details the characteristics of successful community liaison programs, which facilitate transitions from hospital to home, and describes how such programs can reduce the risk of medication discrepancies.

This news piece details the pervasiveness of unreported medical errors and describes the hospitalist perspective on initiatives to improve reporting and prevent adverse events.

This news article uses an example of a preventable readmission to illustrate how ineffective communication during care transitions can affect patients after hospital discharge.

Drawing from surveys of nurses and patients, this article offers tips on how to improve safety during a hospital stay.

This monthly selection of medication error reports provides examples of misinterpretation of dose information, mix-ups of look-alike fluid bags, and error-prone abbreviations.

The authors describe the team-based process they used to improve medication management at the admission, transfer, and discharge stages of patient care at a regional trauma center.

This article discusses the myriad dosing methods that can lead to errors in administering intravenous medications and programming infusion pumps.

This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.

This article reports on three patient deaths due to errors at a state-owned nursing home for veterans.

This article discusses the weaknesses inherent in using the "five rights" for medication use as absolutes and suggests that they instead serve as broad goals to support safe medication practices.

The authors describe elements and key success factors of redesigning medication delivery and administration to support medication reconciliation.