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Maxwell E, Amerine J, Carlton G, et al. Am J Health Syst Pharm. 2021;78(Suppl 3):s88-s94.
Clinical decision support (CDS) tools are intended to enhance care decision and delivery processes. This single-site retrospective study evaluated whether a CDS tool can reduce discharge prescription errors for patients receiving a medication substitution at admission. Findings indicate that use of CDS did not result in a decrease in discharge prescription omissions, duplications, or inappropriate medication reconciliation.
Slikkerveer M, van de Plas A, Driessen JHM, et al. J Patient Saf. 2021;17(7):e587-e592.
Anticoagulants, such as low-molecular-weight heparin (LMWH), are known to be high-risk for adverse drug events. This cross-sectional study identified prescribing errors – primarily lack of dosage adjustment for body weight and/or renal function – among one-third of LMWH users admitted to one hospital over a five-month period.

Ridge K. London, England: Crown Copyright; 2021. September 22, 2021.

Overprescribing has attained prominence as a safety issue due to the current opioid epidemic, but it has long reduced medication safety across the spectrum of health care. The report examines the systemic and cultural issues that contribute to overprescribing and recommends a governmental leadership position to drive change and implement deprescribing and other reduction initiatives.

This case describes multiple emergency department (ED) encounters and hospitalizations experienced by a middle-aged woman with sickle cell crisis and a past history of multiple, long admissions related to her sickle cell disease. The multiple encounters highlight the challenges of opioid prescribing for patients with chronic, non-cancer pain.

Gregory H, Cantley M, Calhoun C, et al. Am J Emerg Med. 2021;46:266-270.
Medication safety continues to be a challenge in most healthcare settings, including emergency departments. In this academic emergency department, an overall error rate of 16.5% was observed, including errors in directions, quantity prescribed, and prescriptions written with refills. Involving a pharmacist at discharge may increase patient safety.

Thomas K, Gebeloff R, Silver-Greenberg J. New York Times. September 11, 2021.

Nursing home medication misuse is a contributor to resident harm. This story highlights system influences such as staffing shortages, reporting failures and normalization of prescribing behaviors that coincide with the misuse of antipsychotic medications and overdiagnosis of schizophrenia.
Khawagi WY, Steinke DT, Carr MJ, et al. BMJ Qual Saf. 2021;Epub Aug 27.
Patient safety indicators (PSIs) can be used to identify potential patient safety hazards. Researchers used the Clinical Practice Research Datalink GOLD database to examine prevalence, variation, and patient- and practice-level risk factors for 22 mental health-related PSIs for medication prescribing and monitoring in primary care. The authors found that potentially inappropriate prescribing and inadequate medication monitoring commonly affected patients with mental illness in primary care.
King CR, Abraham J, Fritz BA, et al. PLoS ONE. 2021;16(7):e0254358.
Analysis of canceled medication orders has been used to estimate medication ordering errors. Using the same dataset analyzed in their 2017 study, the authors update the analysis using machine learning to predict medication ordering errors and associated factors. Results indicate machine learning may be useful in understanding risk factors involved with medication ordering errors.
Agnoli A, Xing G, Tancredi DJ, et al. JAMA. 2021;326(5):411-419.
Sudden discontinuation of opioids has been linked to increased patient harm. This observational study evaluated the link between tapering and overdose, and mental health crisis among patients who were receiving long-term opioid therapy. Patients who underwent dose tapering had an increased risk of overdose and mental health crisis compared to those who did not undergo dose tapering. 
Hoyle JD, Ekblad G, Woodwyk A, et al. Prehosp Emerg Care. 2021:1-8.
Inaccurate assessment of pediatric patient weight can lead to medication dosing errors. In simulated pediatric scenarios, pre-hospital emergency medical services (EMS) crews obtained patient weight using one or more of three methods: asking parent, using patient age, and Broselow-Luten Tape (BLT). BLT was the most frequent method used and patient age resulted in the most frequent dosing errors. Systems-based solutions are presented.
Paradissis C, Cottrell N, Coombes ID, et al. Ther Adv Drug Saf. 2021;12:204209862110274.
Adverse drug events are a common source of harm in both inpatient and ambulatory patients. This narrative review of 75 studies concluded that cardiovascular medications are a leading cause of medication harm across different clinical settings, and that older adults are at increased risk. Medications to treat high blood pressure and arrhythmias were the most common cause of medication harm.
Wei W, Coffey W, Adeola M, et al. Am J Health Syst Pharm. 2021;Epub Jul 15.
Smart pumps can improve medication safety, but barriers such as workarounds and alert fatigue can limit their effectiveness. After implementing smart pumps with an electronic health record (EHR) system, this community hospital saw increased drug library compliance and fewer infusions generating alerts.
Blum MR, Sallevelt B, Spinewine A, et al. BMJ. 2021;374:n1585.
Older adults with multimorbidity and polypharmacy are at increased risk of adverse drug events. This cluster randomized controlled trial compared drug-related hospitalization rates of older adults who received a structured deprescribing intervention and those who received usual care. While rates of polypharmacy decreased, there was no effect on drug-related hospitalizations.
Alshehri GH, Ashcroft DM, Nguyen J, et al. Drug Saf. 2021;44(8):877-888.
Adverse drug events (ADE) can occur in any healthcare setting. Using retrospective record review from three mental health hospitals, clinical pharmacists confirmed that ADEs were common, and that nearly one-fifth of those were considered preventable.
Galanter W, Eguale T, Gellad WF, et al. JAMA Netw Open. 2021;4(7):e2117038.
One element of conservative prescribing is minimizing the number of medications prescribed. This study compared the number of unique, newly prescribed medications (personal formularies) of primary care physicians across four health systems. Results indicated wide variability in the number of unique medications at the physician and institution levels. Further exploration of personal formularies and core drugs may illuminate opportunities for safer and more appropriate prescribing.
Jaam M, Naseralallah LM, Hussain TA, et al. PLOS ONE. 2021;16(6):e0253588.
Including pharmacists can improve patient safety across the medication prescribing continuum. This review identified twelve pharmacist-led educational interventions aimed at improving medication safety. The phase, educational strategy, patient population, and audience varied across studies; however most showed some reductions in medication errors.
Adie K, Fois RA, McLachlan AJ, et al. Br J Clin Pharmacol. 2021;Epub May 23.
Medication errors are a common cause of patient harm. This study analyzed medication incident (MI) reports from thirty community pharmacies in Australia. Most errors occurred during the prescribing stage and were the result of interrelated causes such as poor communication and not following procedures/guidelines. Further research into these causes could reduce medication errors in the community.
Kern-Goldberger AR, Kneifati-Hayek J, Fernandes Y, et al. Obstet Gynecol. 2021;138(2):229-235.
Patient misidentification errors can result in serious patient harm. The authors reviewed over 1.3 million electronic orders for inpatients at one New York hospital between 2016 and 2018 and found that wrong-patient order errors occurred more frequently on obstetric units than medical-surgical units. Medication errors were the largest source of order errors and commonly involved antibiotics and opioid and non-opioid analgesics.
Khan NF, Booth HP, Myles P, et al. BMC Health Serv Res. 2021;21.
This study assessed how and when quality improvement (QI) feedback reports on prescribing safety are used in one general practice in the UK. Four themes were identified: receiving the report, facilitators and barriers to acting upon the report, acting upon the report, and how the report contributes to a quality culture. Facilitators included effective dissemination of reports while barriers included lack of time to act upon the reports. As most practitioners indicated the QI reports were useful, efforts should be made to address barriers to acting upon the reports.