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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.

The prescribing and provision of medications sought after for abuse carries with it a professional obligation to limit access to medications when requests are of uncertain origin. This article describes legal, cognitive, and organizational culture influences on safe prescribing of controlled substances.

The growing use of telehealth can increase patient access to timely care, but also presents patient safety considerations. The use of telehealth to deliver health care services continues to expand. This systematic review included six studies examining safety and quality issues in community pharmacy-based telepharmacy services. Findings suggest that telepharmacies perform similarly or slightly better than traditional pharmacies in terms of medication safety and adherence, but the authors note a high risk of bias amongst the studies which limits the ability to draw definitive conclusions about patient safety and quality-related outcomes.

Older adults are at increased risk of medicine self-administration errors (MSEs) due to polypharmacy, cognitive decline, and decline in physical abilities. In this review, incorrect dosing was the most common MSE; the most common factor influencing the errors is complex medication regimens due to the need for multiple medications. Additional research is needed into how community pharmacists can assist older adults at risk of MSE.

Community pharmacists play an important role in patient safety. In this longitudinal study, community pharmacists reported 1,013 medication incidents, mainly at the prescribing and dispensing stages. Recommended prevention strategies included improved patient safety culture, adherence to organizational policies and procedures, and healthcare provider education.

Clinicians commonly use free-text to generate electronic prescriptions (e-prescriptions); however, these e-prescriptions often require double-checking and transcription by pharmacist staff to avoid potential medication errors. This retrospective study found that about half of the patient directions on e-prescriptions contained at least one quality issue (e.g., dose, frequency of administration) and that pharmacy staff spend significant time and effort identifying and correcting these issues.

Polypharmacy – particularly in older adults – can increase the risk of adverse drug events. Based on an ethnographic case study of community pharmacies in England, the authors found that polypharmacy was a pervasive problem but rarely discussed as a safety concern and not actively challenged by pharmacy staff.

Resolving medication errors often requires coordination between different care providers. This qualitative study examined medication safety incidents at one VA hospital and found that health care providers rely on cognitive decentering, collaborative decision-making, back-up behaviors, and contingency planning to coordinate care during medication safety incidents. The primary barriers to care coordination identified were role ambiguity, breakdowns in care, and electronic health record-related challenges.

Communicating medication indications with the healthcare team and patients can improve medication adherence and patient safety. Based on qualitative interviews with prescribers, researchers found that prescribers were open to sharing medication indications and understood the safety benefits, but raised concerns about the impact on their workflow and workload.

Medication reconciliation can improve patient safety, but prior research has documented challenges with implementation. Researchers conducted a gap analysis to inform the development of standardized medication reconciliation framework for use across multiple healthcare settings to reduce harm, including during the COVID-19 pandemic. Five key components were identified: (1) pharmacy-led medication reconciliation team, (2) patient education and involvement, (3) complete and accurate medication history, (4) admission and discharge reconciliation, and (5) interprofessional communication.