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Plymouth Meeting, PA: Institute for Safe Medication Practices; 2022.
This updated report describes best practices to ensure safety when preparing sterile compounds, including pharmacist verification of orders entered into computerized provider order entry systems. The guidelines emphasize the role of technologies such as barcoding and robotic image recognition as approaches to enhance safety. In addition, it covers safe practices when technologies are not available.
Uitvlugt EB, Heer SE, van den Bemt BJF, et al. Res Soc Admin Pharm. 2022;18:2651-2658.
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.
Hall N, Bullen K, Sherwood J, et al. BMJ Open. 2022;12:e050283.
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. 

Institute for Safe Medication Practices.

Workplace bullying and disrespectful behavior have been shown to negatively affect fall rates, medication errors, and other adverse events. The Institute for Safe Medication Practices is seeking clinician input on and experiences with disrespectful behaviors in the ambulatory care setting (e.g., community, specialty, and long-term care pharmacies, physician practices, and outpatient visits) and how organizations have been working to improve the culture of respect. The survey will be open until May 27, 2022.
Coates MC, Granche J, Sefcik JS, et al. Res Gerontol Nurs. 2022;15:69-75.
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.
Peat G, Olaniyan JO, Fylan B, et al. Res Social Adm Pharm. 2022;Epub Jan 28.
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.

Medication Safety Alert! Acute care edition. January 27, 2022;27(2):1-6.

Medication errors are a consistent threat to safe patient care. This newsletter article analyzes events submitted to the Institute for Safe Medication Practices in 2021 and highlights those that are COVID-related or common, yet preventable, if practice recommendations and system improvements are applied.
Mercer K, Carter C, Burns C, et al. JMIR Hum Factors. 2021;8:e22325.
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.

Cohen M, Degnan D, McDonnell P, eds. Patient Saf. 2022;4(s1):1-45

Pharmacists play a unique role in patient safety that educational methods are shifting to address. This special issue covers several topics including strategies to reduce the susceptibility of hospitalized infants and children to medication errors, and infusing safety culture into pharmacy school curriculum.

Institute for Safe Medication Practices. Medication Safety Alerts. January 3, 2022.

Emerging care practices can produce unsafe situations due to the newness of the approaches involved. This alert highlights safety considerations with an oral antiretroviral COVID treatment that include medication administration problems. Safety recommendations are provided for prescribers and pharmacists.

Georgia Galanou Luchen, Pharm. D., is the Director of Member Relations at the American Society of Health-System Pharmacists (ASHP). In this role, she leads initiatives related to community pharmacy practitioners and their impact throughout the care continuum. We spoke with her about different types of community pharmacists and the role they play in ensuring patient safety. 

ISMP Medication Safety Alert! Acute care edition. October 7, 2021;26(20):1-4.

Production pressure and low staff coverage can result in medication mistakes in community pharmacies. This article shares reported vaccine errors and factors contributing to mistaken administration of flu and COVID vaccines. Storage, staffing and collaboration strategies are shared to protect against vaccine mistakes.
Shervani S, Madden W, Gleason LJ. JAMA Intern Med. 2021;181:1383-1384.
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.
Clabaugh M, Beal JL, Illingworth Plake KS. J Am Pharm Assoc (2003). 2021;61:761-771.
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.
Watterson TL, Stone JA, Brown RL, et al. J Am Med Inform Assoc. 2021;28:1526-1533.
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.
Adie K, Fois RA, McLachlan AJ, et al. Br J Clin Pharmacol. 2021;87:4809-4822.
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.