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Farnborough, UK: Healthcare Safety Investigation Branch; September 24, 2020. 

Unit-based pharmacy services help to mitigate and catch medication errors. This report highlights a case of a medication error death and describes how embedding clinical pharmacy services could have prevented this incident. The report provides system level recommendations to enhance this service including defining the role of clinical pharmacy teams and prioritizing the tactic as an important improvement strategy.   
Guirguis A. The Pharmaceutical Journal. 2020;304.
Users of illicit substances are vulnerable to a variety of health concerns. This article discusses how the COVID-19 pandemic places illicit drug users at increased risk for COVID-19 due to their predisposition to infection and social contact; how disruptions to illicit drug supply chains increase risk for overdose due to drug substitution and; the impact of missing out on drug treatment services. The piece highlights the role of pharmacists in keeping this marginalized patient population safe.

NHS Improvement. Independent Mortality Review of Cardiac Surgery at St George’s University Hospitals NHS Foundation Trust. NHS England. March 2020.

In-depth incident investigations provide details of care process examinations to motivate learning and improvement. This report examines cardiac surgery patient mortality at a National Health Service Trust over a 5-year period. It highlights weakness in professionalism at the individual and organization level as a contributor to the preventable patient deaths catalogued over that time.