Safe practice in community pharmacy is challenged by production pressure, workforce shortages, and multitasking. This story examined the mistakes made at major retail pharmacy chains in California. It provides examples perpetrated across the industry to target universal areas of needed improvement and potential strategies to address them.

Drug diversion can reduce patient safety and should be addressed at a system level to reduce its occurrence and impact. Part I of this two-part series examines ways in which drug diversion can affect care teams, and outlines what to watch for to flag its occurrence at the clinician, record keeping, and medication inventory levels. Part II shares tactics to minimize controlled substance diversion, and track, document and take action when it does occur.

Suboptimal working conditions are a known contributor to errors in retail pharmacies. This news article discusses how one major pharmacy chain will adjust their staff quality metrics to eliminate timing as a performance measure in the interest of reducing pharmacist and staff burnout and fulfilment errors.

Criminalization of medical mistakes typifies the blame-focused approach patient safety leaders have worked to reduce in health care. This article covers a high-profile case of medication error involving an automated dispensing system that is ubiquitous in health care.

Electronic health record alerting functions are ubiquitous elements of decision support systems. This news article introduces how they detract from safe care delivery and provide protections against unsafe, missed, or delayed care.

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.

Multitasking can negatively affect cognitive load and diminish safety. This magazine article reports on how multitasking can contribute to surgeon fatigue, burnout, and decreased task completion in the perioperative environment. Checklists to automate workflow and limiting the number of patient charts that can be open at one time can help reduce extraneous cognitive load.

This newsletter article reviews common problems related to patient identification and recommends strategies to ensure verification actions are a part of daily practice. Highlighted suggestions focus on system-level approaches that reduce the potential for incorrect patient data to be entered and proliferate, such as use of frontline confirmation processes and duplicate record monitoring. A WebM&M commentary discussed an incident involving a wrong-patient order in an electronic record system.

High-alert medications have the potential to cause serious patient harm. This article focuses on four primary types of high-alert medications—anticoagulants, sedatives, insulins, and opioids—that can have serious adverse effects and recommends strategies to reduce risks, including conducting independent double-checks and decreasing interruptions.

Operating rooms are complex environments with particular risks regarding interruptions and distractions. This article draws from data reported to the Patient Safety Authority to explore how distractions affect surgeons and other team members. The author reviews strategies to limit distractions, including applying sterile cockpit principles, performing preoperative briefings, and utilizing checklists.

Analyzing data submitted to the Pennsylvania Patient Safety Reporting System, this piece outlines the types of distractions that contribute to medical errors and recommends strategies to mitigate them. 

This news article highlights the risks and benefits of using mobile technology in health care. An AHRQ WebM&M commentary discusses the error mentioned, in which a text message interrupted a medication order.

Reporting on widespread use of mobile devices (such as iPads and smartphones) in health care, this newspaper article details how technological distractions may increase the risk of errors. A recent AHRQ WebM&M commentary, written by Harvard CIO John Halamka, discusses a case in which a physician, interrupted by a non–work-related text message on a smartphone, forgets to discontinue a dangerous medication.

This news story shares the results of a nine-hospital program to improve the safety of medication delivery through minimizing nursing interruptions.

This article discusses work space factors that can affect safe medication delivery, including lighting, interruptions, noise level, and physical space design.