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Pharmacists play a critical role in medication safety during transitions of care. This multi-center study found that a transitional pharmacy care program (including teach-back, pharmacy discharge letter, home visit by community pharmacist, and medication reconciliation by both the community and hospital pharmacist) did not decrease the proportion of patients with adverse drug events (ADE) after hospital discharge. The authors discuss several possible explanations as to why the intervention did not impact ADEs and suggest that a process evaluation is needed to explore ways in which a transitional pharmacy care program could reduce ADEs.

Reporting errors is a key component of improving patient safety and patient care. Primary care prescribers and community pharmacists in Northeast England were interviewed about perceived barriers and enablers to reporting medication prescribing errors, either internally or externally. Motivation, capability, and opportunity influenced reporting behaviors. 

Older adults, especially those taking multiple medications, are at increased risk for medication self-administration (MSE) errors. Data from the National Health and Aging Trends Study (NHATS) was analyzed to ascertain if the source of the medication ­– picking up from local pharmacy, receiving the medication via mail-order pharmacy, or both ­– impacted MSE or hospitalization. Respondents receiving medications via both mail-order and pick up were more likely to report hospitalizations and medication mistakes.

The COVID-19 pandemic has impacted all aspects of healthcare delivery for both patients and health care workers. This study explored the how COVID-19-related policies and initiatives intended to improve patient safety impacted workflow, system adaptations, as well as organizational and individual resilience among community pharmacists.

Clear communication regarding medication indications can improve patient safety. This scoping review explored how including the indication on a prescription may impact prescribing practice. Studies suggest that including the indication can help identify errors, support communication, and improve patient safety, but prescribers noted concerns about impacts on workflow and patient privacy.

Prior research has found that electronic health record systems (EHRs) cannot effectively communicate medication discontinuation instructions to pharmacies. This “teachable moment” commentary highlights this issue with EHR and pharmacy system interoperability which resulted in the inadvertent dispensing of a discontinued medication. A related commentary discusses the challenges associated with attempting to discontinue prescriptions and how the CancelRx system can help mitigate these challenges.

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.

Prior research has found that ambulatory electronic health records cannot communicate medication discontinuation instructions to pharmacies. In this study, the implementation of the CancelRx system led to a significant, sustained increase in successful medication discontinuations and reduced the time between medication discontinuation in the clinic EHR and pharmacy dispensing software.

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.